Texas Health and Human Services Commission and Office of Inspector General v. Antoine Dental Center
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Opinion
ACCEPTED 06-15-00076-CV SIXTH COURT OF APPEALS TEXARKANA, TEXAS 11/9/2015 4:47:09 PM DEBBIE AUTREY CLERK
No. 06-15-00076-CV
FILED IN In the Court of Appeals for the 6th COURT OF APPEALS Sixth Judicial District TEXARKANA, TEXAS 11/10/2015 8:06:00 AM Texarkana, Texas DEBBIE AUTREY Clerk Texas Health and Human Services Commission, AND Office of Inspector General, Appellants, v. Antoine Dental Center, Appellee. th On Appeal from the 200 Judicial District Court of Travis County, Texas Cause No. D-1-GN-14-002229 Hon. Amy Clark Meachum, Presiding BRIEF OF APPELLANTS Respectfully submitted, RAYMOND CHARLES WINTER State Bar No. 21791950 Office of the Attorney General Chief, Civil Medicaid Fraud Division
CHARLES E. ROY REYNOLDS B. BRISSENDEN First Assistant Attorney General State Bar No. 24056969
JAMES E. DAVIS NOAH REINSTEIN Deputy Attorney General for Civil State Bar No. 24089769 Litigation Assistant Attorneys General Office of the Texas Attorney General P.O. Box 12548, Capitol Station MC 056-1 Austin, Texas 78711-2548 Telephone: (512) 936-1709 Facsimile: (512) 370-9477 Raymond.Winter@texasattorneygeneral.gov Attorneys for Texas Health and Human Services Commission and Office of Inspector General Submitted: November 9, 2015 ORAL ARGUMENT REQUESTED IDENTITY OF PARTIES AND COUNSEL
Pursuant to Tex. R. App. P. 38.1(a), appellant presents the following list of all parties and names and addresses of counsel:
Appellant/Defendant at District Court: Texas Health and Human Services Commission and Office of Inspector General
Counsel: Raymond C. Winter Reynolds B. Brissenden Noah Reinstein Office of the Texas Attorney General P.O. Box 12548 Austin, Texas 78711-2548 Telephone: (512) 936-1709 Facsimile: (512) 370-9477
Appellee/Plaintiff at District Court: Antoine Dental Center
Counsel: Jason Ray Riggs & Ray, PC 506 W. 14th Street, Suite A Austin, Texas 78701 Telephone: (512) 457-9812 Facsimile: (512) 457-9066
ii TABLE OF CONTENTS
IDENTITY OF PARTIES AND COUNSEL ...................................................... ii
TABLE OF CONTENTS ..................................................................................... iii
INDEX OF AUTHORITIES ............................................................................... vi
STATEMENT OF THE CASE .............................................................................2
STATEMENT REGARDING ORAL ARGUMENT .........................................3
ISSUES PRESENTED ...........................................................................................3
STATEMENT OF FACTS ....................................................................................4
I. The Texas Medicaid program provides health care for the indigent, including limited orthodontia services..................................................4 A. Medicaid provides a limited benefit for orthodontics. ........................4 B. Providers must obtain prior authorization by accurately and honestly representing that their patient has a severe handicapping malocclusion before they may request reimbursement for orthodontic services. ...............................................................................6 1. Providers are required to rely on their education and training in making diagnoses, requesting prior authorization, and making claims for Medicaid reimbursement. ...................7 2. “Ectopic eruption” is an exceedingly rare condition, and in the TMPPM the term is afforded the meaning generally understood in the practice of dentistry. ....................................8 II. HHSC-OIG is responsible for protecting Medicaid from waste, fraud and abuse. OIG is required by law to impose a payment hold based on a credible allegation that a provider has committed Medicaid fraud. .....................................................................................10 III. Antoine billed Texas Medicaid for more than $8 million in orthodontia services over a three-year period, and OIG placed Antoine on payment hold. ....................................................................14 IV. Antoine requested a hearing on the payment hold, and, after the
iii hearing and the ALJs’ recommendation that HHSC order OIG to lift the hold, the EC reversed the PFD and ordered the hold to remain in place. .....................................................................................19
STANDARD OF REVIEW .................................................................................21
SUMMARY OF THE ARGUMENT ..................................................................24
ARGUMENT ........................................................................................................25
I. The EC acted within his discretion to correct misapplications of Medicaid law and policy by the SOAH ALJs. ...................................25 A. The proper interpretation of Texas Medicaid policy is a question of law to be determined by the EC. The EC properly interpreted Medicaid policy in harmony with the governing statutes and regulations, and Antoine has shown no basis for the Court to deviate from the EC’s correct interpretation. ............................................................................27 B. The EC’s corrections of the ALJs’ errors in interpreting Medicaid policy are entitled to respect from the Court. .......29 II. The EC did not exceed his authority in entering the AFO and Antoine cannot establish otherwise.....................................................32 A. The ALJs misunderstood and misapplied Texas Medicaid law and policy and the EC corrected the misunderstanding with a proper construction of law and policy. ........................33 1. The rules of statutory construction govern questions of agency policy and administrative rules. ..............................37 2. The ALJs ignored statutes, rules, and evidence and made fundamental errors in interpreting and applying Texas Medicaid policy. The misapplications were properly corrected by the EC. .............................................................38 B. Substantial evidence exists to show that Antoine committed fraud or made willful misrepresentations necessary to maintain the payment hold. The EC properly corrected the ALJs’ errors, and Antoine cannot establish that the EC exceeded his authority. .............................................................43 1. Providers have a duty to know and follow law and policy.
iv .................................................................................................44 2. Dr. Kanaan’s scoring pattern shows, at a minimum, he acted with conscious disregard or reckless indifference to the truth or falsity of his representations of patient conditions. ..............................................................................45 3. The ALJs compounded their errors by relying on “experts” who misunderstood and misapplied Texas Medicaid policy......................................................................47 III. Every modification made in the EC’s AFO is supported by substantial evidence and Antoine cannot establish otherwise..........49 A. Finding of Fact No. 45...............................................................49 B. Finding of Fact No. 46...............................................................51 C. Finding of Fact No. 47...............................................................52 D. Finding of Fact No. 48...............................................................54 E. Finding of Fact No. 49...............................................................56 F. Finding of Fact No. 50...............................................................57 G. Conclusion of Law No. 13. ........................................................58
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ACCEPTED 06-15-00076-CV SIXTH COURT OF APPEALS TEXARKANA, TEXAS 11/9/2015 4:47:09 PM DEBBIE AUTREY CLERK
No. 06-15-00076-CV
FILED IN In the Court of Appeals for the 6th COURT OF APPEALS Sixth Judicial District TEXARKANA, TEXAS 11/10/2015 8:06:00 AM Texarkana, Texas DEBBIE AUTREY Clerk Texas Health and Human Services Commission, AND Office of Inspector General, Appellants, v. Antoine Dental Center, Appellee. th On Appeal from the 200 Judicial District Court of Travis County, Texas Cause No. D-1-GN-14-002229 Hon. Amy Clark Meachum, Presiding BRIEF OF APPELLANTS Respectfully submitted, RAYMOND CHARLES WINTER State Bar No. 21791950 Office of the Attorney General Chief, Civil Medicaid Fraud Division
CHARLES E. ROY REYNOLDS B. BRISSENDEN First Assistant Attorney General State Bar No. 24056969
JAMES E. DAVIS NOAH REINSTEIN Deputy Attorney General for Civil State Bar No. 24089769 Litigation Assistant Attorneys General Office of the Texas Attorney General P.O. Box 12548, Capitol Station MC 056-1 Austin, Texas 78711-2548 Telephone: (512) 936-1709 Facsimile: (512) 370-9477 Raymond.Winter@texasattorneygeneral.gov Attorneys for Texas Health and Human Services Commission and Office of Inspector General Submitted: November 9, 2015 ORAL ARGUMENT REQUESTED IDENTITY OF PARTIES AND COUNSEL
Pursuant to Tex. R. App. P. 38.1(a), appellant presents the following list of all parties and names and addresses of counsel:
Appellant/Defendant at District Court: Texas Health and Human Services Commission and Office of Inspector General
Counsel: Raymond C. Winter Reynolds B. Brissenden Noah Reinstein Office of the Texas Attorney General P.O. Box 12548 Austin, Texas 78711-2548 Telephone: (512) 936-1709 Facsimile: (512) 370-9477
Appellee/Plaintiff at District Court: Antoine Dental Center
Counsel: Jason Ray Riggs & Ray, PC 506 W. 14th Street, Suite A Austin, Texas 78701 Telephone: (512) 457-9812 Facsimile: (512) 457-9066
ii TABLE OF CONTENTS
IDENTITY OF PARTIES AND COUNSEL ...................................................... ii
TABLE OF CONTENTS ..................................................................................... iii
INDEX OF AUTHORITIES ............................................................................... vi
STATEMENT OF THE CASE .............................................................................2
STATEMENT REGARDING ORAL ARGUMENT .........................................3
ISSUES PRESENTED ...........................................................................................3
STATEMENT OF FACTS ....................................................................................4
I. The Texas Medicaid program provides health care for the indigent, including limited orthodontia services..................................................4 A. Medicaid provides a limited benefit for orthodontics. ........................4 B. Providers must obtain prior authorization by accurately and honestly representing that their patient has a severe handicapping malocclusion before they may request reimbursement for orthodontic services. ...............................................................................6 1. Providers are required to rely on their education and training in making diagnoses, requesting prior authorization, and making claims for Medicaid reimbursement. ...................7 2. “Ectopic eruption” is an exceedingly rare condition, and in the TMPPM the term is afforded the meaning generally understood in the practice of dentistry. ....................................8 II. HHSC-OIG is responsible for protecting Medicaid from waste, fraud and abuse. OIG is required by law to impose a payment hold based on a credible allegation that a provider has committed Medicaid fraud. .....................................................................................10 III. Antoine billed Texas Medicaid for more than $8 million in orthodontia services over a three-year period, and OIG placed Antoine on payment hold. ....................................................................14 IV. Antoine requested a hearing on the payment hold, and, after the
iii hearing and the ALJs’ recommendation that HHSC order OIG to lift the hold, the EC reversed the PFD and ordered the hold to remain in place. .....................................................................................19
STANDARD OF REVIEW .................................................................................21
SUMMARY OF THE ARGUMENT ..................................................................24
ARGUMENT ........................................................................................................25
I. The EC acted within his discretion to correct misapplications of Medicaid law and policy by the SOAH ALJs. ...................................25 A. The proper interpretation of Texas Medicaid policy is a question of law to be determined by the EC. The EC properly interpreted Medicaid policy in harmony with the governing statutes and regulations, and Antoine has shown no basis for the Court to deviate from the EC’s correct interpretation. ............................................................................27 B. The EC’s corrections of the ALJs’ errors in interpreting Medicaid policy are entitled to respect from the Court. .......29 II. The EC did not exceed his authority in entering the AFO and Antoine cannot establish otherwise.....................................................32 A. The ALJs misunderstood and misapplied Texas Medicaid law and policy and the EC corrected the misunderstanding with a proper construction of law and policy. ........................33 1. The rules of statutory construction govern questions of agency policy and administrative rules. ..............................37 2. The ALJs ignored statutes, rules, and evidence and made fundamental errors in interpreting and applying Texas Medicaid policy. The misapplications were properly corrected by the EC. .............................................................38 B. Substantial evidence exists to show that Antoine committed fraud or made willful misrepresentations necessary to maintain the payment hold. The EC properly corrected the ALJs’ errors, and Antoine cannot establish that the EC exceeded his authority. .............................................................43 1. Providers have a duty to know and follow law and policy.
iv .................................................................................................44 2. Dr. Kanaan’s scoring pattern shows, at a minimum, he acted with conscious disregard or reckless indifference to the truth or falsity of his representations of patient conditions. ..............................................................................45 3. The ALJs compounded their errors by relying on “experts” who misunderstood and misapplied Texas Medicaid policy......................................................................47 III. Every modification made in the EC’s AFO is supported by substantial evidence and Antoine cannot establish otherwise..........49 A. Finding of Fact No. 45...............................................................49 B. Finding of Fact No. 46...............................................................51 C. Finding of Fact No. 47...............................................................52 D. Finding of Fact No. 48...............................................................54 E. Finding of Fact No. 49...............................................................56 F. Finding of Fact No. 50...............................................................57 G. Conclusion of Law No. 13. ........................................................58
CERTIFICATE OF COMPLIANCE .................................................................61
CERTIFICATE OF SERVICE ...........................................................................61
INDEX OF APPENDIX .......................................................................................62
v INDEX OF AUTHORITIES
Cases
Akin v. Tex. State Bd. of Dental Exam’rs, No. 03-14-00390-CV, 2015 WL1611803, (Tex. App.—Austin Apr. 9, 2015, no pet.hist.).........................24, 25, 26, 28, 43, 59
Atascosa Cnty. v. Atascosa Cnty. Appraisal Dist., 990 S.W. 2d 255 (Tex.1999)...29
Bd. of Law Exam’rs v. Stevens, 868 S.W.2d 773 (Tex. 1994), cert. denied, Stevens v. Bd. of Law Exam’rs, 512 U.S. 1206, 114 S.Ct. 2676 (1994)…………...............22
Bd. of Trs. of the Emps. Ret. Sys. v. Benge, 942 S.W.2d 742 (Tex. App.—Austin 1997, writ denied)....................................................................................................22
Boswell v. Brazos Electric Power, 910 S.W.2d 593 (Tex. App.—Fort Worth 1995, writ denied)........................................................................................................37, 42
Bridgestone/Firestone, Inc. v. Glyn-Jones, 878 S.W.2d 132 (Tex.1994)…….38, 40
City of El Paso v. Pub. Util. Comm’n, 883 S.W.2d 179 (Tex. 1994)..........22, 23, 32
City of Waco v. Tex. Comm’n Envtl. Quality, 346 S.W.3d 781(Tex. App. —Austin 2011, rev’d on other grounds 413 S.W.3d 409 (Tex. 2013))…..............................32
Cont’l Cas. Ins. Co. v. Functional Restoration Assocs.,19 S.W.3d 393 (Tex. 2000)........................................................................................................................37
Employees Ret. Sys. of Texas v. Garcia, 454 S.W.3d 121 (Tex. App.—Austin 2014), pet. denied (Sept. 4, 2015)………………...…….......…………………21, 32
Exxon Corp. v. R.R. Comm'n, 993 S.W.2d 704 (Tex. App.—Austin 1999, no pet.)..........................................................................................................................27
Fitzgerald v. Advanced Spine Fixation Sys., Inc.,996 S.W.2d 864 (Tex. 1999).....37
Flores v. Emps. Ret. Sys. of Tex., 74 S.W.3d 532 (Tex. App.—Austin 2002, pet. denied).....................................................................................................................49
Froemming v. Tex. State Bd. of Dental Exam’rs, 380 S.W.3d 787 (Tex. App.— Austin 2012, no pet.)...................................................................................24, 26, 28
vi Gomez v. Tex. Educ. Agency, 354 S.W.3d 905 (Tex. App.—Austin 2011, pet. denied).....................................................................................................................29
Graff Chevrolet Co. v. Tex. Motor Vehicle Bd., 60 S.W.3d 154 (Tex. App.—Austin 2001, pet. denied).........................................................................................22-23, 24
Granek v. Texas State Bd. of Med. Exam'rs, 172 S.W.3d 761 (Tex. App.—Austin 2005, no pet.)...........................................................................................................59
Gulf States Utils. Co. v. Pub. Util. Comm’n,841 S.W.2d 459 (Tex. App.—Austin 1992, writ denied)....................................................................................................22
Harlingen Family Dentistry v. Tex. Health & Human Servs. Comm’n, 452 S.W.3d 479 (Tex. App.—Austin 2014, pet. filed)................................................................18
Heckler v. Community Health Servs., 467 U.S. 51(1984)..................................43-44
Heritage on the San Gabriel v. Tex. Comm’n on Envt’l Quality, 393S.W.3d 417(Tex. App.—Austin 2012, pet. denied).......................................................32, 49
In re: E.I. DuPont de Nemours & Co., 136 S.W.3d 218 (Tex. 2004).....................13
Levy v. Tex. State Bd. of Medical Exam’rs, 966 S.W.2d 813 (Tex. App.–Austin 1998, no pet.)...........................................................................................................49
Lewis v. Southmore Savings Ass’n, 480 S.W.2d 180 (Tex. 1972)...........................23
Liberty Mut. Ins. Co. v. Garrison Contractors, Inc., 966 S.W.2d 482 (Tex. 1998)……...……………………………………………………………...... 37
Locklear v. Tex. Dep’t of Ins., 30 S.W.3d 595 (Tex. App.—Austin 2000, no pet.)………………………………………………………………………………..23
N. Mem’l Med. Ctr. v. Gomez, 59 F. 3d 735 (8th Cir. 1995)...................................45
Personal Care Products, Inc. v. Hawkins, 635 F. 3d 155 (5th Cir. 2001)..............44
Pierce v. Tex. Racing Comm’n, 212 S.W.3d 745 (Tex. App.—Austin 2006, pet. denied)…………………………....... …………………………...……………49, 59
R.R. Comm’n of Tex. v. Tex. Citizens for a Safe Future & Clean Water, 336 S.W. 3d 619 (Tex. 2011)…..…................................................................28, 29, 32, 37, 38
vii Rehak Creative Servs. v. Witt, 404 S.W.3d 716 (Tex. App.—Houston [l4th Dist.] 2013, pet. denied)....................................................................................................55
Sanchez v. Tex. State Bd. of Med. Exam’rs, 229 S.W.3d 498 (Tex. App.—Austin 2007, no pet.)...............................................................................................24, 27, 50
Smith v. Montemayor, 03-02-00466-CV, 2003 WL 21401591 (Tex. App.—Austin June 19, 2003, no pet.)...........................................................................26, 27, 28, 50
State v. Pub. Util. Comm’n, 883 S.W.2d 190(Tex. 1994)...........................21, 22, 32
State v. Terrell, 588 S.W.2d 784 (Tex.1979).....................................................37-38
State v. Mid-South Pavers, Inc., 246 S.W.3d 711(Tex. App.–Austin 2007, pet. denied).....................................................................................................................49
Sw. Pharm. Solutions, Inc., v. Tex. Health & Human Servs. Comm’n, 408 S.W.3d 549 (Tex. App.—Austin 2013, pet. denied).........................28, 29, 30-31, 32, 42, 48
Tex. Ass’n of Psychological Assocs. v. Tex. State Bd. of Exam’rs of Psychologists, 439 S.W.3d 597602 (Tex. App.—Austin 2014, no pet.).........................................23
Tex. Emp’t Comm’n v. Hays, 360 S.W.2d 525 (Tex. 1962)...............................21-22
Tex. Health Facilities Comm’n. v. Charter Med.-Dallas, Inc., 665 S.W.2d 446 (Tex.1984)...............................................................................................................21
Tex. State Bd. of Med. Exam’rs v. Birenbaum, 891 S.W.2d 333 (Tex. App.—Austin 1995, writ denied)....................................................................................................22
Tex. State Bd. of Med. Exam’rs v. Dunn, 03-03-00180-CV, 2003 WL 22721659 (Tex. App.—Austin Nov. 20, 2003, no pet.)..........................................26-27, 49, 50
Tex. State Bd. of Dental Exam’rs v. Sizemore, 759 S.W.2d 114 (Tex. 1988).........22
Tex. Tech Univ. Health Scis. Ctr. v. Apodaca, 876 S.W.2d 402 (Tex. App.—El Paso 1994, writ denied)...........................................................................................13
TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432 (Tex. 2011)…............40
United States v. Carbajal, 290 F.3d 277 (5th Cir. 2002)........................................12
viii United States v. Floyd, 343 F.3d 363 (3d Cir. 2003)...............................................12
Wood v. Tex. Comm’n Envtl. Quality, No. 13-13-00189-CV, 2015 WL 1089492 (Tex. App.—Corpus Christi, Mar. 5, 2015, no pet.).........................................26, 48
Zimmer US, Inc. v. Combs, 368 S.W.3d 579 (Tex. App.—Austin 2012, no pet)....30
Federal Regulations/Statutes
42 C.F.R. § 455.2...............................................................................................12, 46 42 C.F.R. § 455.23.............................................................................2, 11, 12, 18, 58 42 C.F.R. § 455.23(a)(1)....................................................................................11-12 42 U.S.C. §1395........................................................................................................4 42 U.S.C. §1396..................................................................................................4, 11
State Regulations
1 Tex. Admin. Code § 155.507(c)(1)......................................................................19 1 Tex. Admin. Code § 357.483(a)(1)-(2)................................................................20 1 Tex. Admin. Code § 357.488(b)...........................................................................20 1 Tex. Admin. Code § 357.497...............................................................................19 1 Tex. Admin. Code § 357.497(e)...........................................................................20 1 Tex. Admin. Code § 371.1...................................................................................10 1 Tex. Admin. Code § 371.1605.............................................................................11 1 Tex. Admin. Code § 371.1617(a)(1)(A)-(C)........................................................58 1 Tex. Admin. Code § 371.1617(a)(3)....................................................................20 1 Tex. Admin. Code § 371.1617(5)(B)...................................................................11 1 Tex. Admin. Code § 371.1617(1)(A)...................................................................18 1 Tex. Admin. Code § 371.1617(1)(B)...................................................................18 1 Tex. Admin. Code § 371.1617(1)(I).....................................................................18 1 Tex. Admin. Code § 371.1617(1)(K)...................................................................18 1 Tex. Admin. Code § 371.1617(2)(A)...................................................................18 1 Tex. Admin. Code § 371.1703(b)(3)....................................................................58 25 Tex. Admin. Code § 33.71....................................................4-5, 6, 34, 36, 39, 41
State Statutes
Tex. Gov’t Code § 311.002(4).................................................................................37 Tex. Gov’t Code § 311.011(a)...........................................................................38, 39 Tex. Gov’t Code § 311.011(b)...........................................................................38, 41 Tex. Gov’t Code § 311.021(2) ......................................................................... 38, 41
ix Tex. Gov’t Code § 311.021(3)...........................................................................38, 41 Tex. Gov’t Code § 311.021(4)...........................................................................38, 41 Tex. Gov’t Code § 311.021(5)...........................................................................38, 41 Tex. Gov’t Code § 311.023(1)...........................................................................38, 41 Tex. Gov’t Code § 311.023(5)...........................................................................38, 41 Tex. Gov’t Code § 311.023(6).....................................................................29, 38, 41 Tex. Gov’t Code § 312.005.....................................................................................37 Tex. Gov’t Code § 531.001................................................................................10-11 Tex. Gov’t Code § 531.0055(b)(1)............................................................................4 Tex. Gov’t Code § 531.1011(1)...............................................................................12 Tex. Gov’t Code § 531.102.....................................................................................10 Tex. Gov’t Code § 531.102(a).................................................................................18 Tex. Gov’t Code § 531.102(g).................................................................................58 Tex. Gov’t Code § 531.102(g)(2)............................................................2, 11, 18, 47 Tex. Gov’t Code § 2001.058(e)...................................................................26, 27, 59 Tex. Gov’t Code § 2001.058(e)(1)....................................................................24, 26 Tex. Gov’t Code § 2001.062(b)...............................................................................19 Tex. Gov’t Code § 2001.174...................................................................................21 Tex. Gov’t Code § 2001.174(1)...............................................................................21 Tex. Gov’t Code § 2001.174(2)...............................................................................23 Tex. Gov’t Code § 2001.175(e)...............................................................................21 Tex. Hum. Res. Code § 32.0291(b).............................................................13, 18, 19 Tex. Hum. Res. Code § 32.0291(c).....................................................................2, 13 Tex. Hum. Res. Code § 32.032(b)(1)......................................................................10 Tex. Hum. Res. Code § 32.091(c)...........................................................................58 Tex. Hum. Res. Code § 36.0011(a).......................................................11, 53, 55, 56 Tex. Hum. Res. Code § 36.0011(b)...................................................................53, 56
Secondary Sources
F. Scott McCown & Monica Leo, When Can an Agency Change the Findings of Conclusions of an ALJ?: Part Two, 51 Baylor L. Rev. 63, 69-70 (1999)………………………………………………...……….……….26, 27, 50
x No. 06-15-00076-CV
In the Court of Appeals for the Sixth Judicial District Texarkana, Texas
Texas Health and Human Services Commission, AND Office of Inspector General, Appellants, v.
Antoine Dental Center, Appellee. th On Appeal from the 200 Judicial District Court of Travis County, Texas Cause No. D-1-GN-14-002229 Hon. Amy Clark Meachum, Presiding
TO THE HONORABLE SIXTH COURT OF APPEALS:
The Texas Health and Human Services Commission (“HHSC”), and the Office
of Inspector General (“OIG”) (collectively “State”) respectfully request that this
Court reverse the district court’s decision, which reversed HHSC’s entry of an
Amended Final Order (“AFO”) sustaining a payment hold against Antoine Dental
Center (“Antoine”) for violations of Texas law and regulations related to the
Medicaid program.
HHSC Executive Commissioner Dr. Kyle Janek (“EC”) acted within his
authority in entering the AFO, which is supported by substantial evidence. The
district court erred in reaching its decision that the AFO should be reversed because
the AFO is reasonably supported by substantial evidence and because the EC acted
1 within its statutory authority in entering the AFO. At the district court, Antoine
failed to meet its burden to show otherwise. Therefore, the AFO should be affirmed
by this Court.
STATEMENT OF THE CASE
The EC, on behalf of HHSC, issued the AFO, affirming a payment hold
imposed by HHSC-OIG on Antoine. Tex Hum. Res. Code § 32.0291(c); Tex.
Gov’t Code § 531.102(g)(2); 42 C.F.R. § 455.23. See Appendix A, HHSC’s
AFO, dated May 2, 2014 (copy also at A.R. 1743-85).1 Antoine filed a suit for
judicial review appealing the AFO. The district court reversed the AFO without
giving any explanation for its reversal. Aggrieved by the district court order, the
State timely filed this appeal.
1 The pleadings and copies of the hearing transcript, contained within HHSC’s Administrative Record (“A.R.”), are labeled with the Bates prefix “00001” through “2795.” The A.R. was admitted as Exhibits 1 and 2 in the district court and is part of the clerk’s record.
2 STATEMENT REGARDING ORAL ARGUMENT
Pursuant to Tex. R. App. P. 38.1(e), the State respectfully requests oral
argument. Antoine’s position, if accepted, would severely undermine the State’s
efforts to punish and deter fraud in the Medicaid program, which comprises a quarter
of the State’s budget. An adverse decision would likely impede the State’s efforts
to enforce numerous other public-welfare statutes that expressly authorize the State
to sue wrongdoers in the health and medical fields. The State believes that oral
argument will assist the Court’s decisional process; and the importance of the matter
and the intricacies of the relevant statutes and Medicaid policies warrant oral
argument.
ISSUES PRESENTED
I. The EC acted within his discretion to correct misapplications of Medicaid law and policy by the SOAH ALJs.
II. The EC did not exceed his authority in entering the AFO and Antoine cannot establish otherwise.
III. Every modification made in the EC’s AFO is supported by substantial evidence and Antoine cannot establish otherwise.
3 STATEMENT OF FACTS
I. The Texas Medicaid program provides health care for the indigent, including limited orthodontia services.
The federal government enacted the Medicaid program in 1965 to help the
states provide healthcare for the indigent. Medicaid is funded jointly by federal and
state government, as mandated by federal law. 42 U.S.C. § 1396. In Texas, the
agency responsible for administering Medicaid is HHSC. Tex. Gov’t Code §
531.0055(b)(1).2
A. Medicaid provides a limited benefit for orthodontics.
Texas Medicaid provides coverage for orthodontic services to qualifying
children on a very limited basis. 3 The law restricts when Texas Medicaid will pay
for orthodontic services:
Orthodontic services for cosmetic reasons only are not a covered Medicaid service. Orthodontic services must be prior authorized and are limited to treatment of severe handicapping malocclusion and other related conditions as described and measured by the procedures and standards published in the TMPPM [(“Texas Medicaid Provider Procedures Manual”)].
2 Currently more than 4.5 million Texans are enrolled in Medicaid. See http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/texas.html, Appendix B. In 2013, Medicaid comprised about 26.2 percent of the Texas state budget, amounting to approximately $25.6 billion dollars. See Pink Book, 1-1, Appendix C. 3 HHSC administers the Medicaid program pursuant to Texas’s “Medicaid state plan.” The state plan, is reviewed and approved by the federal Centers for Medicare & Medicaid Services. Tex. Gov’t Code § 531.097.
4 25 Tex. Admin. Code § 33.71 (emphasis added). Since 2003, the Texas Medicaid
orthodontia benefit policy has covered orthodontic services under limited scenarios.
Relevant to this matter is coverage for children between the ages of 12 and 20 who
have dysfunction and a severe handicapping malocclusion which is defined by an
accurate and honest Handicapping Labio-lingual Deviation (“HLD”) score of 26
points or greater. Texas Medicaid does not pay, nor has it ever paid, for cosmetic
orthodontics. See, e.g., TMPPM (2011) (Ex. R-17), Vol. 2, § 4.2.24, copy at
Appendix D; TMPPM (2010) (Ex. R-16),Vol. 2, § 5.3.24 (same), copy at
Appendix E; TMPPM (2009), Vol. 2, § 19.19 (Ex. R-15) (same), copy at
Appendix F; 4 TMPPM (2008), Vol. 2 § 19.18 (Ex. R-14), copy at Appendix G.
See also 25 Tex. Admin. Code § 33.71 (same). In all qualifying cases,
comprehensive orthodontic treatment (i.e. “full banding” or “full braces,”) is only
available for children twelve years of age to twenty (at the time of prior
authorization) who have lost their baby teeth. See Ex. R-15 at § 19.19.6; App. F.
4 The TMPPM states: 19.19 Orthodontic Services (THSteps): Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid. Orthodontic services are limited to the treatment of children who are 12 years of age and older with severe handicapping malocclusion…
19.19.1 Benefits and Limitations: Orthodontic services include the following: Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index…A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered)…
Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps.
5 B. Providers must obtain prior authorization by accurately and honestly representing that their patient has a severe handicapping malocclusion before they may request reimbursement for orthodontic services.
Providers must submit a prior authorization request, and receive approval,
before seeking reimbursement for orthodontic services. See 25 Tex. Admin. Code §
33.71; see also Ex. R-15 at § 19.19.2; App. F. “Prior authorization is a condition for
reimbursement; it is not a guarantee of payment.” Id. Providers are required to
submit truthful and complete information when seeking prior authorization.5
The prior authorization application includes the provider’s certification that a
child has a severe handicapping malocclusion and the treatment is necessary to
correct it. To support a finding that a child has a severe handicapping malocclusion,
a provider must, inter alia, submit an HLD scoresheet accurately evaluating the
patient. See Ex. R-15 at § 19.19.2 (2009); App. F. A prior authorization request is
generally approved if the child has a severe handicapping malocclusion, as indicated
by an honest score of 26 or more on the HLD. See id. 6
5 Specifically, providers are required to submit: • An orthodontic treatment plan, which “should incorporate only the minimal number of appliances required to properly treat the case”; • “[c]ephalometric radiograph with tracing models”; • “[c]ompleted and scored HLD score sheet with diagnosis of Angle class (26 points required for approval of non-cleft palate cases.”); • Facial photographs; • Full series of radiographs or a panoramic radiograph; diagnostic films are required. Id., at App. F. 6 For a patient for whom the provider scores less than 26, the provider may submit a written narrative to qualify for benefits. This did not occur with the patients in this case
6 1. Providers are required to rely on their education and training in making diagnoses, requesting prior authorization, and making claims for Medicaid reimbursement.
The HLD allows providers to score nine specific dental conditions in a
patient’s mouth. The conditions identified on the HLD scoresheet are conditions that
are generally recognized in dentistry, including but not limited to: ectopic eruption,
cleft palate, overjet, overbite, and mandibular protrusion (“underbite”). The
condition most relevant in this case is ectopic eruption.
The TMPPM instructs providers how to score using the HLD scoresheet. The
instructions include a description of ectopic eruption. See, e.g., Ex. R-15 at § 19.21
(2009), at App. F. The TMPPM does not define ectopic eruption for the purposes
Texas Medicaid. HHSC’s policy expert Dr. Altenhoff testified that the terms in the
ectopic eruption instruction are not defined, but, rather, are accorded their plain and
ordinary meaning in the English language. Vol. 1 at 103:8-12, A.R. at 1914; see also
R-88, Proffer of Rebuttal Testimony from Dr. Linda Altenhoff (Medicaid did not
intend, at any time, for the term “‘ectopic eruption’ to have a different meaning when
used in the evaluation of Medicaid patients than is generally understood in the
practice of dentistry” and “dentists [were] expected to employ the training and
education they received as dentists in applying the terms used in the Provider
Manual”), Appendix J; and Vol. 3 at 241:5-11 (where Deputy Inspector General for
Enforcement testified to the same proposition), A.R. at 2528.
7 2. “Ectopic eruption” is an exceedingly rare condition, and in the TMPPM the term is afforded the meaning generally understood in the practice of dentistry.
“Ectopic eruption” is a rare dental condition – occurring in only 1.5 to 9
percent of the population 7 – primarily affecting the first molars, upper and lower
canines.8 Scientific literature describes the low frequency of ectopic eruption
occurring even once per patient. See R-51, (ectopic eruption only occurring in 1.5-
1.6% of a sample population), at App. H. The frequency of the same rare condition
occurring multiple times and/or bilaterally in the same patient is “infinitesimally
smaller.” 9 The chance of 100% of the patients in a sample having not only one
instance of a rare condition, but always at least 6 instances, and always two or more
bilateral instances, is “zero. It’s not possible.” 10
OIG’s orthodontic expert, Dr. Larry Tadlock, described that ectopic eruption,
as explained in Dr. William Proffit’s textbook Contemporary Orthodontics, means
a tooth that erupts in the wrong place.11 The Proffit textbook, a leading orthodontic
textbook, explains that ectopic eruption is caused by malposition of a permanent
7 Vol. 1 at 173:3-6, A.R. at 1984; see also R-51 at 8 (Thilander article describing ectopic eruption as an “anomaly” occurring in only 1.5-1.6% of a sample population of 4724 patients), Appendix H. 8 Vol. 1 at 153:22-24, A.R. at 1964. 9 Vol. 1 at 174:16-17, A.R. at 1985. 10 Id. at 174:1, A.R. at 1985; R-49, Tadlock summary, at A.R. 1097-98, Appendix I. 11 Id.at 114:18-23, A.R. at 1925.
8 tooth bud and most commonly occurs in the maxillary first molars. 12 “Ectopic
eruption of other teeth is rare, but can result in transposition.” 13 The following
photographs provide examples of ectopic eruption:
R-31A (showing upper and lower ectopically-erupted canines (images of non-
Antoine patients provided by Dr. Tadlock)), at A.R. 1031.14
See R-31L (showing an ectopically-erupted upper left central incisor (image of non-
Antoine patient provided by Dr. Tadlock)). 15 All of the scientific literature surveyed
by Dr. Tadlock describe ectopically erupted teeth as teeth that erupt “in the wrong
12 Id. at 143:17-18, 144:13-15, A.R. at 1954. 13 Id. at 145:8-10, A.R. at 1956. 14 See Vol. 1 at 149 for Dr. Tadlock’s description of this non-Antoine patient’s condition, at A.R. 1960. Compare photos of Antoine patients, included infra at p. 18. 15 Id. at 150 for Dr. Tadlock’s description of this image, at A.R. 1961. Compare photos of Antoine patients, included infra at p. 18.
9 place.”16 Teeth can ectopically erupt in sinus cavities, or through the side of the
face. 17 Based upon the well-known dental term, the vast majority of teeth that
Antoine represented to Medicaid as being ectopic eruptions were not ectopic
eruptions.
II. HHSC-OIG is responsible for protecting Medicaid from waste, fraud and abuse. OIG is required by law to impose a payment hold based on a credible allegation that a provider has committed Medicaid fraud.
OIG is an independent oversight agency, administratively attached to HHSC.
OIG is responsible for investigating instances of waste, fraud and abuse in health
care services provided by HHSC, including Medicaid, and for enforcing state laws
relating to the provision of those services. Tex. Gov’t Code § 531.102; see also 1
Tex. Admin. Code § 371.1. Chapter 32 of the Human Resources Code authorizes
the OIG to recover damages and penalties from a person who presents or causes to
be presented to the department a claim that “contains a statement or representation
the person knows or should know to be false.” Tex. Hum. Res. Code § 32.032(b)(1).
The statutory authority for the rules governing OIG includes both chapters 32
and 36 of the Human Resources Code, and OIG may take administrative
enforcement measures against a person based upon a violation of either chapter. See
16 Id. at 153, at A.R. 1964. 17 Id. at 146:3-8, at A.R. 1957.
10 Tex. Gov’t Code § 531.001 et seq.; 1 Tex. Admin. Code § 371.1605 (2005); 1 Tex.
Admin. Code § 371.1617(5)(B) (2005) (which references and incorporates the Texas
Medicaid Fraud Prevention Act (“TMFPA”)). Therefore, the standard in the TMFPA
for determining whether a person acts with the requisite scienter to commit an
unlawful act is applicable in an enforcement action brought by the OIG, including a
payment hold proceeding. See Tex. Hum. Res. Code § 36.0011(a) (defining Culpable
Mental State).18
OIG is required by law to impose a payment hold “on receipt of reliable
evidence that the circumstances giving rise to the hold on payment involve fraud or
willful misrepresentation under the state Medicaid program in accordance with 42
C.F.R. Section 455.23.”19 Tex. Gov’t Code § 531.102(g)(2) (2011). “The State
Medicaid agency must suspend all Medicaid payments to a provider after the agency
determines there is a credible allegation of fraud for which an investigation is
pending under the Medicaid program against an individual or entity.” 42 C.F.R. §
18 For purposes of this chapter, a person acts “knowingly” with respect to information if the person: (1)has knowledge of the information; (2) acts with conscious indifference to the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information. Proof of the person's specific intent to commit an unlawful act under Section 36.002 is not required in a civil or administrative proceeding to show that a person acted “knowingly” with respect to information under this chapter. Id. 19 The mandatory payment-hold framework was introduced through provisions of the Affordable Care Act, which amended the Social Security Act. Section 1862(o) broadly requires suspension of payments pending an investigation of credible allegations of fraud. 42 U.S.C. § 1396b(i)(2)(c). Section 1903(2)(c) provides for withholding of federal funds where the State fails to implement section 1862(o). 42 U.S.C. § 1395y(o)
11 455.23(a)(1) (emphasis added).
Fraud is defined in the Government Code as “an intentional deception or
misrepresentation made by a person with the knowledge that the deception could
result in some unauthorized benefit to the person or to another person, and includes
any act that constitutes fraud under applicable federal or state law.” Tex. Gov’t
Code § 531.1011(1)20 (emphasis added). The definition incorporates unlawful acts
under the TMFPA.
A credible allegation of fraud “may be an allegation, which has been
verified by the State, from any source, including but not limited to the following:
. . . claims data mining [,] . . . patterns identified through provider audits [or] law
enforcement investigations.” 42 C.F.R. § 455.2. An allegation is credible if it has
“indicia of reliability and the State Medicaid agency has reviewed all allegations,
facts, and evidence carefully and acts judicially on a case-by-case basis.” Id.
Evidence is presumed to have indicia of reliability and may be adopted by
a court “without further inquiry if the defendant fails to demonstrate by competent
rebuttal evidence that the information is materially untrue, inaccurate or
unreliable.” United States v. Floyd, 343 F.3d 363, 372-73 (3rd Cir. 2003) (citing
United States v. Carbajal, 290 F.3d 277, 287 (5th Cir. 2002)).
20 In 2015, the legislative amended this statute to delete the italicized language. The amendment did not take effect until September 2015; therefore, it is not applicable to this case.
12 OIG has additional authority to impose a payment hold if there is “reliable
evidence” a provider “committed fraud or willful misrepresentation regarding a
claim for reimbursement.” Tex. Hum. Res. Code § 32.0291(b) (2003).21 The
authority in Human Resources Code chapter 32 is duplicative of the authority in
Government Code chapter 531. However, § 32.0291(c) includes the standard for
maintaining the payment hold: “The department shall discontinue the hold unless
the department makes a prima facie showing at the hearing that the evidence relied
on by the department in imposing the hold is relevant, credible and material to the
issue of fraud or willful misrepresentation.” Tex. Hum. Res. Code § 32.0291(c)
(emphasis added).22
This means in a payment hold hearing, the OIG must present prima facie
evidence that is relevant, credible and material, that the provider acted with: (1)
knowledge of the truth or falsity of its representations; (2) conscious indifference
to the truth or falsity of its representations; or (3) reckless disregard of the truth or
falsity of its representations. Tex. Hum. Res. Code §§ 32.0291(c), 36.011.
(emphasis added).
21 Effective September 1, 2013 section 32.0291(b) of the Human Resources Code was amended. A new subsection (c) was added to the statute. The changes are prospective and do not apply to this case, which was heard in May 2013. 22 See In re E.I. DuPont de Nemours & Co., 136 S.W.3d 218, 223 (Tex. 2004) (“The prima facie standard requires only the ‘minimum quantum of evidence necessary to support a rational inference that the allegation of fact is true.’ Tex. Tech Univ. Health Scis. Ctr. v. Apodaca, 876 S.W.2d 402, 407 (Tex. App.—El Paso 1994, writ denied). ”).
13 III. Antoine billed Texas Medicaid for more than $8 million in orthodontia services over a three-year period, and OIG placed Antoine on payment hold.
Between November 1, 2008 and August 1, 2011, Medicaid paid Antoine
over $8,104,875.00, FoF 3, App. A at p. 3, at A.R. 1748. OIG initiated an
investigation of Antoine in 2011. Vol. 3, 195:1, A.R. at 2482. During the time
period of the investigation, Antoine treated approximately 6,550 Medicaid
patients. Vol. 3 at 200:12, A.R. at 2487. During its investigation, OIG collected a
statistically valid random sample 23 of 63 of Antoine’s Medicaid patient files. Vol.
3 at 200:20-208:7, A.R. at 2787.
The 63 patient files, which included diagnostic materials (x-rays, color
photographs, three-dimensional models, etc.) were independently reviewed by two
orthodontic experts: Dr. Charles Evans and Dr. Larry Tadlock. Based on the expert
review of the 63-patient sample, OIG instituted a 100% payment hold on Antoine’s
claims for reimbursement. 24 FoF 32, App. A at p. 13, at A.R.1756.
Both orthodontic experts relied upon their education and training in
23 OIG’s statistically valid sampling methodology was not at issue in the payment hold hearing. The only evidence regarding the validity of OIG’s sampling and extrapolation procedure is uncontroverted. See testimony of Deputy Inspector General for Enforcement, Vol 3, at 201-209, A.R. at 2488-96.
24 Dr. Tadlock reviewed the sample after the payment hold was instituted, for purposes of testifying at the payment hold hearing regarding the patient files.
14 reviewing the patient files to evaluate the patients’ conditions, and each expert
individually followed the TMPPM criteria for the corresponding years of service
(2008-2011). Both experts independently concluded Antoine inflated HLD scores
submitted to Medicaid. Vol. 3 at 289:23-290:3, 295:22-296:2, A.R. at 2576-77,
2582-83. OIG presented the following evidence, based on the experts’ review of
the 63 patients:
• Of the 63 patients, Antoine scored 61 (96.8%) as having severe handicapping malocclusions, i.e., extreme deviations from the norm. See R-49, at A.R. 1097-98, App. I.
• Antoine certified that 61 patients had six or more ectopically-erupted teeth. Ex. P-64.01 through P-64.63; R-49, at A.R. 1097-98, App. I.
• Antoine scored at least 50% of the allowable teeth as ectopic on each and every HLD scoresheet Antoine submitted for authorization. See R-49, at A.R. 1097-98, App. I.
• No patient in the sample was eligible for Medicaid-covered comprehensive orthodontics without Antoine’s scoring for ectopic eruption; further, Antoine did not submit any narratives for any of the 61 patients, even if services could be justified on other bases. Ex. P- 64.01 through P-64.63; Vol. 4 at 70:13-19, A.R. at 2698.
• Dr. Kanaan scored 27 of the 63 patients’ HLDs. Of those 27 patients, he scored 23 (85%) with the same eight teeth ectopic. Vol. 3 at 43-70, A.R. at 2330-57. Ex. P-64.01 through P- 64.63; R-49, at A.R. 1097-98, App. I.
• Antoine submitted prior authorization requests for comprehensive orthodontics under the code D8080 for 61 of the 63 patients. Ex. P- 64.01 through P-64.63; Vol. 1, 176:14-20, 177:1-16, A.R. at 1987-88.
Dr. Larry Tadlock, D.D.S., 25testified:
25 Dr. Tadlock is a board-certified orthodontist. He is an Assistant Clinical Professor of
15 • Antoine’s HLD scoresheets were false and misrepresented the condition of the patient’s teeth. Vol. 1 at 176:14- 20, 177:1-16, A.R. at 1987-88.
• 61 of 63 HLD scoresheets were incomprehensible because ectopic eruption is a rare condition. Only 1.5-9% of the population has even one ectopic tooth. Vol. 1 at 173:3-6, A.R. at 1984; see also R-51 at 8 (Thilander article describing ectopic eruption as an “anomaly” that occurs in only 1.5-1.6% of a sample population of 4724 patients), App. H.
• For ectopic eruption to occur more than once in the same patient is “infinitesimally smaller.” Vol. 1 at 174:16-18, A.R. at 1985. See also R-31L, supra, at p. 9.
• Because ectopic eruption is rare, occurring in between 1.5-9% of the population, the chances of 61 patients in the 63-patient sample having 6 or more ectopic anterior teeth is “not possible.” Vol. 1 at 173:3-6, 175:1, A.R. at 1984, 1986.
• The chance of 100% of patients in a sample having always at least six instances of ectopic eruption, and always two or more bilateral instances, is “zero. It’s not possible.” Vol. 1 at 175:1, 176:23, A.R. at 1986-87; R-49, Tadlock summary, at A.R. 1097-98, App. I.
The following shows Antoine’s scoring of patients in the 63-patient sample:
Patient 1: Pre-treatment intra-oral photos of Antoine Patient 1, P-01-0001:26
Orthodontics at Baylor College of Dentistry, responsible for supervising patient care, teaching orthodontic residents, and performing research on orthodontics. He is one of only eight directors of the American Board of Orthodontics (“ABO”) in the United States. As an ABO Director, Dr. Tadlock is responsible for creating, writing, and administering board certification exam for orthodontists. Specific to his experience with Medicaid, Dr. Tadlock has treated Medicaid patients who were accepted and treated at Baylor. He estimates he has assessed “several hundred” HLD scoresheets for potential Medicaid patients while at Baylor. Vol. 1 at 146-48, A.R. at 1957-59.
26 Dr. Tadlock concluded “[t]his patient’s occlusion is near perfect. . . . it might qualify as passing the certification process from the American Board of Orthodonti[cs]. Vol. 1 at 158:18- 23. Compare photos of true ectopic eruptions, included supra at p. 9.
16 Antoine’s HLD scoresheet representing that Patient 1 has 8 ectopic teeth. P 01- 0013:
Patient 6:
Pre-treatment intra-oral photos of Antoine Patient 6. P-06-0003:27
06-0001
27 This patient does not have a single ectopic tooth according to Dr. Tadlock, and does not have a severe handicapping malocclusion. Vol. 1 at 160:14-24, A.R.at 1971.
17 Patient 59:
Pre-treatment intra-oral photos of Antoine Patient 59, P-59-0018:
Antoine’s HLD scoresheet representing that Patient 59 has 10 ectopic teeth. P-59-0017:
OIG based its decision to impose the payment hold on prima facie
evidence that Antoine fraudulently or willfully misrepresented HLD scores in
prior authorization requests, in violation of Tex. Gov’t Code § 531.102(a), and
1 Tex. Admin. Code §§ 371.1617(1)(A), (B), (I). 28
28 OIG also found that Antoine billed for services not reimbursable, in violation of 1 Tex. Admin. Code § 371.1617(1)(K); and failed to maintain and provide required records, in violation of 1 Tex. Admin. Code § 371.1617(2)(A). As a result, Antoine failed to comply with Medicaid program requirements, and a payment hold was authorized under the Inspector General’s discretionary authority. However, the Inspector General’s authority to impose discretionary payment holds was challenged and then struck in Harlingen Family Dentistry v. Tex. Health & Human Servs. Comm’n, 452 S.W.3d 479 (Tex. App.—Austin 2014, pet. filed). Therefore, the State confines its arguments to the mandatory payment hold under the credible allegation of fraud standard as codified in 42 C.F.R. § 455.23, Tex. Gov’t Code § 531.102(g)(2) (2011), and Tex. Hum. Res. Code § 32.0291(b).
18 IV. Antoine requested a hearing on the payment hold, and, after the hearing and the ALJs’ recommendation that HHSC order OIG to lift the hold, the EC reversed the PFD and ordered the hold to remain in place.
Antoine requested a hearing to appeal the payment hold. SOAH ALJs
Howard Seitzman and Catherine Egan conducted a hearing in May 2013. The issue
was whether OIG presented prima facie evidence that was relevant, credible and
material that Antoine committed fraud or willful misrepresentations. Tex. Hum.
Res. Code § 32.0291(b).
The burden was not on the OIG to actually prove fraud or willful
misrepresentations; rather, the question was only whether OIG brought forward
prima facie evidence sufficient to maintain the payment hold. 29
After the hearing, ALJs Seitzman and Egan issued a PFD recommending
that HHSC order OIG to lift the payment hold. PFD, dated Nov. 4, 2013, A.R. at
1193-1238. OIG timely filed Exceptions to the PFD. Tex. Gov’t Code §
2001.062(b); 1 Tex. Admin. Code §§ 155.507(c)(1), 357.497. See Exceptions,
dated Nov. 22, 2013, A.R. at 1257-1344. Antoine filed a Response to OIG’s
Exceptions, and the ALJs issued a letter recommending an insignificant
modification to their PFD. See Letter, dated Jan. 16, 2014, A.R. at 1375-76.
29 The substantive allegations of Medicaid fraud against Antoine are pending in a separate lawsuit brought by the State against Antoine and five other groups of provider defendants. State of Texas v. Nazari, Cause No. D-1-GN-14-005380 (53rd Dist. Ct., Travis County, Texas).
19 HHSC issued a Final Order, adopting the OIG’s Exceptions and maintaining the
payment hold. See Order, dated Feb. 27, 2013, A.R. at 1387-1422. HHSC’s Final
Order was issued by HHSC ALJ Rick Gilpin, who the EC designated to review
the PFD and issue the final agency decision. See 1 Tex. Admin Code §
371.1617(a)(3); 1 Tex. Admin Code § 357.483(a)(1)-(2). Subsequently, OIG filed
a motion for rehearing. Mot., dated Apr. 2, 2014, A.R. at 1552-1650.30 After
reviewing the record, the EC issued the AFO. See Am. Final Order, dated, May 2,
2014, at App. A, and A.R. at 1744-85.
Antoine filed a motion for rehearing, which HHSC overruled. A.R. at 1787-
1810. Antoine then filed for judicial review in district court. After briefing and
argument, but without the submission of any evidence other than the
administrative record, the district court entered a judgment stating that the EC’s
AFO is reversed. The district court gave no explanation for the reversal. This
appeal followed.
30 Antoine also filed a motion for rehearing, erroneously with SOAH instead of with HHSC Appeals Division. Mot., dated Mar. 17, 2014, A.R. at 1423-65; see also Tex. Gov’t Code § 2001.146 (motions for rehearing procedures); 1 Tex. Admin. Code § 357.488(b) (Filing and Serving of Documents (“Documents are considered filed only when received by the HHSC Appeals Division. . .”); 1 Tex. Admin. Code § 357.497(e) (“When the judge issues a proposal for decision, the referring agency’s rules govern final orders and motions for rehearing.”). Because Antoine filed the motion for rehearing in the wrong forum, the motion was a nullity, and the EC was free to disregard it.
20 STANDARD OF REVIEW
The test for review of an agency action is not whether the agency reached the
correct conclusion, but whether some reasonable basis for the agency’s action exists
in the record. State v. Pub. Util. Comm’n, 883 S.W.2d 190, 203 (Tex. 1994) (citing
R.R. Comm’n v. Pend Oreille Oil & Gas Co., 817 S.W.2d 36, 41 (Tex. 1991)).
The district court reviewed HHSC’s AFO under the substantial evidence rule.
Tex. Gov’t Code § 2001.174. The Administrative Procedure Act (“APA”) provides
that the district court “may not substitute its judgment for the judgment of the state
agency on the weight of the evidence on questions committed to agency discretion
but . . . may affirm the agency decision in whole or in part” if the order is supported
by substantial evidence. Tex. Gov’t Code § 2001.174(1). The district court’s review
was limited to the administrative record. Tex. Gov’t Code § 2001.175(e). This Court
also reviews the AFO under the substantial evidence rule, without deference to the
judgment of the district court. Tex. Dep’t. of Pub. Safety v. Alfred, 209 S.W.3d 101,
103 (Tex. 2006) (per curiam). Employees Ret. Sys. of Texas v. Garcia, 454 S.W.3d
121, 132 (Tex. App.—Austin 2014 pet. denied).
The Court may affirm the AFO on any grounds that would support the
decision, and is not “bound by the reasons given by an agency in its order, provided
there is a valid basis for the action taken by the agency.” Tex. Health Facilities
Comm’n. v. Charter Med.-Dallas, Inc., 665 S.W.2d 446, 452 (Tex. 1984); see also
21 Tex. Emp’t Comm’n v. Hays, 360 S.W.2d 525, 527 (Tex. 1962). The Court may
uphold the AFO based on any legal basis shown in the record. Bd. of Trs. of the
Emps. Ret. Sys. v. Benge, 942 S.W.2d 742, 744 (Tex. App.—Austin 1997, writ
denied). If reasonable minds could have reached the conclusion that the EC
reached on the record presented, the AFO must be upheld. Bd. of Law Exam’rs v.
Stevens, 868 S.W.2d 773, 777-788 (Tex. 1994), cert. denied, Stevens v. Bd. of Law
Exam’rs, 512 U.S. 1206, 114 S. Ct. 2676 (1994); Tex. State Bd. of Med. Exam’rs
v. Birenbaum, 891 S.W.2d 333, 337 (Tex. App.— Austin 1995, writ denied).
In applying the substantial evidence standard to the AFO, the Court may not
substitute its judgment for that of the EC as to the weight of the evidence on
questions committed to his discretion. Stevens, 868 S.W.2d at 778; Gulf States
Utils. Co. v. Pub. Util. Comm’n, 841 S.W.2d 459, 474 (Tex. App.—Austin 1992,
writ denied). Although substantial evidence is more than a mere scintilla, the
evidence may actually preponderate against the agency decision and yet still
amount to substantial evidence supporting the result reached by the agency. State
v. Pub. Util. Comm’n, 883 S.W.2d at 204; City of El Paso v. Pub. Util. Comm’n,
883 S.W.2d 179, 185 (Tex. 1994); see also Tex. State Bd. of Dental Exam’rs v.
Sizemore, 759 S.W.2d 114, 116 (Tex. 1988).
The Court presumes that substantial evidence supports the AFO, and the
burden is on Antoine to overcome this presumption. Graff Chevrolet Co. v. Tex.
22 Motor Vehicle Bd., 60 S.W.3d 154, 159 (Tex. App.—Austin 2001, pet. denied);
Lewis v. Southmore Savings Ass’n, 480 S.W.2d 180, 183 (Tex. 1972); see also City
of El Paso v. Pub. Util. Comm’n, 883 S.W.2d at 184.
The AFO should be reversed or remanded only if the absence of substantial
evidence has prejudiced Antoine’s substantial rights. Locklear v. Tex. Dep’t of Ins.,
30 S.W.3d 595, 597 (Tex. App.—Austin 2000, no pet.). The Court may only reverse
or remand a matter “for further proceedings”: if substantial rights of Antoine have
been prejudiced because the administrative findings, inferences, conclusions, or
decisions are:
(A) in violation of a constitutional or statutory provision; (B) in excess of the agency’s statutory authority; (C) made through unlawful procedure; (D) affected by other error of law; (E) not reasonably supported by substantial evidence considering the reliable and probative evidence in the record as a whole; or (F) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.
Tex. Gov’t Code § 2001.174(2).
In the district court, Antoine argued that the EC exceeded his authority when
he reversed several of the ALJs’ findings of fact and conclusions of law. Whether
the EC exceeded his authority is a question of law to be decided de novo. See, e.g.,
Tex. Ass’n of Psychological Assocs.v. Tex. State Bd. of Exam’rs of Psychologists,
439 S.W.3d 597, 602 (Tex. App.— Austin 2014, no pet.) (court reviews exercise
of authority de novo).
23 SUMMARY OF THE ARGUMENT
This case presents the issue of whether the EC acted within his authority when
he issued the AFO to maintain the payment hold on Antoine. Because the EC was
fully authorized to correct the ALJs’ misapplications of Medicaid law and policy he
did not exceed his authority when he rejected their PFD and issued the AFO. See
Tex. Gov’t Code § 2001.058(e)(1); Froemming v. Tex. State Bd. of Dental Exam’rs,
380 S.W.3d 787, 793 (Tex. App.—Austin 2012, no pet.); Sanchez v. Tex. State Bd.
of Med. Exam’rs, 229 S.W.3d 498, 516 (Tex. App.—Austin 2007, no pet.); see also
Akin v. Tex. State Bd. of Dental Exam’rs, No. 03-14-00390-CV, 2015 WL 1611803,
at *4-5 (Tex. App.—Austin Apr. 9, 2015, no pet. hist.). Further, the AFO is
supported by substantial evidence in all respects.
In reviewing the decision to issue the AFO, the Court must assume that the
AFO is valid; and to overcome the presumption of validity, Antoine has the burden
to establish that the AFO is not supported by substantial evidence or that the EC
exceeded his statutory authority in issuing the AFO. See Graff Chevrolet, 60
S.W.3d at 159 (plaintiff has burden of proving that agency’s order is not supported
by substantial evidence). In the district court, Antoine did not even argue that the
AFO is not supported by substantial evidence. Instead, Antoine confined its
argument and briefing to the issue of whether the EC exceeded his authority in
changing the ALJs’ findings of fact. Because Antoine did not brief or argue
24 substantial evidence in the district court that issue has been waived. See Akin, 2015
WL 1611803, at *3 n.1 Nonetheless, the State will show that the AFO is fully
supported by substantial evidence in the administrative record that: (a) the ALJs
misinterpreted and misapplied Texas law and Medicaid policy, and (b) the OIG’s
determination to impose the payment hold was based on prima facie evidence that
was relevant, credible and material to the question of fraud or willful
misrepresentation.
The State urges the Court to reverse the district court—i.e. reinstate the
AFO—on the basis that Antoine cannot carry its burden to establish that the AFO
was not supported by substantial evidence, nor can Antoine establish that the EC
exceeded his statutory authority.
ARGUMENT
I. The EC acted within his discretion to correct misapplications of Medicaid law and policy by the SOAH ALJs.
The APA governs contested proceedings before HHSC. The APA expressly
defines the EC’s discretion to change ALJs’ proposed findings of fact and
conclusions of law after contested case hearings. The APA provides, in pertinent
part:
(e) A state agency may change a finding of fact or conclusion of law made by the administrative law judge, or may vacate or modify an order issued by the administrative law judge, only if the agency determines:
25 (1) that the administrative law judge did not properly apply or interpret applicable law, agency rules, written policies provided under Subsection (c), or prior administrative decisions; (2) that a prior administrative decision on which the administrative law judge relied is incorrect or should be changed; or (3) that a technical error in a finding of fact should be changed.
Tex. Gov’t Code § 2001.058(e) (emphasis added). Thus, the EC was authorized to
change the ALJs’ incorrect legal and policy determinations. See Tex. Gov’t Code
§ 2001.058(e)(1); see also Froemming, 380 S.W.3d at 793; Akin, 2015 WL
1611803, at *4-5, *5 n.6; Smith v. Montemayor, 2003 WL 21401591, at *8 (Tex.
App.—Austin June 19, 2003, no pet.); Wood v. Tex. Comm’n Envtl. Quality, No.
13-13-00189-CV, 2015 WL 1089492, at *11 (Tex. App.— Corpus Christi, Mar.
5, 2015, no pet. hist.)
Consistent with the concept that agencies determine the meaning of their
policies and the laws they are committed to enforce, agencies have broad
discretion to modify “legislative facts” in PFDs. 31 See Tex. State Bd. of Med.
Exam’rs v. Dunn, 03-03-00180-CV, 2003 WL 22721659, at *3 (Tex. App.—
31 A “legislative fact” is a mixed question of fact and law and defining terms is an agency function. F. Scott McCown & Monica Leo, When Can an Agency Change the Findings of Conclusions of an ALJ?: Part Two, 51 Baylor L. Rev. 63, 69-70 (1999) (hereinafter “McCown & Leo”). A finding of fact is a “legislative fact” where the finding affects not just one specific case, but is actually an explication of agency policy and therefore may be applied to other cases or implicates agency policy. Id.
26 Austin Nov. 20, 2003, no pet.) (“agencies are ‘relatively’ free to review and correct
an ALJ’s ‘legislative facts,’ which ‘provide a foundation for developing law, rules,
or policies and, consequently, affect the outcome of many cases.’”) (quoting
McCown & Leo, at 68-69); see also Sanchez, 229 S.W.3d at 515-16; Exxon Corp.
v. Railroad Comm'n, 993 S.W.2d 704, 710 (Tex. App.—Austin 1999, no pet.);
Montemayor, 2003 WL 2140151, *8.
The ALJs misconstrued Medicaid policy, ignored evidence, disregarded
competent testimony proffered by OIG, and created “expert” testimony not offered
by Antoine. The EC, acting with sound discretion, corrected the ALJs’ erroneous
interpretations, and their flawed findings and conclusions that flowed from their
initial errors. The EC fully explained each modification, as required by the APA,
demonstrating the substantial evidence necessary to support his modifications. See
Tex. Gov’t. Code § 2001.058(e).
A. The proper interpretation of Texas Medicaid policy is a question of law to be determined by the EC. The EC properly interpreted Medicaid policy in harmony with the governing statutes and regulations, and Antoine has shown no basis for the Court to deviate from the EC’s correct interpretation.
The proper interpretation and application of regulatory/statutory provisions
governing Medicaid and Medicaid policy are questions of law committed to the
discretion of the EC - not the ALJs. Thus, the EC was not bound to accept the
ALJs’ erroneous determinations regarding Medicaid policy concerning “ectopic
27 eruption.” See, e.g., R.R. Comm’n of Tex. v. Tex. Citizens for a Safe Future &
Clean Water, 336 S.W.3d 619, 629 (Tex. 2011) (“We must uphold the enforcing
agency’s construction if it is reasonable and in harmony with the statute.”); Sw.
Pharm. Solutions, Inc., v. Tex. Health & Human Servs. Comm’n, 408 S.W.3d 549,
557-58 (Tex. App.—Austin 2013, pet. denied); Froemming, 380 S.W.3d at 793;
Akin, 2015 WL 1611803, at *4-5.
The Akin court approved the board’s modifications of the ALJ’s proposed
finding and conclusion because the ALJ failed to properly interpret or apply the
statute to facts in evidence. Id. While the ALJ in Akin found Akin did not commit
a dishonest act, the board provided examples of evidence that showed the dentist
was dishonest or practicing dentistry illegally, and the district court upheld the
board’s order reversing the ALJ’s PFD. Id. Akin court also quoted with approval
Montemayor, 2003 WL 21401591, at *8. Akin, 2015 WL 1611803, at *5 n.6
In the instant case, in reversing the AFO (without explanation), the district
court implicitly determined the EC’s interpretation of Medicaid rules—especially
those related to ectopic eruption—was unreasonable and not in harmony with the
statutes he interpreted. The State presented substantial evidence at the district
court, discussed infra, through the admission of the administrative record,32 that
the EC’s interpretation of the Medicaid rules is reasonable and followed long-held
32 No additional evidence was presented at the district court.
28 principles of statutory construction. Antoine presented nothing to counter the EC’s
reasonable interpretation; therefore, the district court should not have disturbed the
EC’s decision.
B. The EC’s corrections of the ALJs’ errors in interpreting Medicaid policy are entitled to respect from the Court.
The EC’s interpretation of the proper scope and limitations of Texas
Medicaid orthodontia policy is entitled to respect from the Court. See Texas
Citizens, 336 S.W.3d at 624; see also Atascosa Cnty. v. Atascosa Cnty. Appraisal
Dist., 990 S.W. 2d 255, 258 (Tex. 1999); Gomez v. Tex. Educ. Agency, 354 S.W.3d
905, 913-17 (Tex. App.—Austin 2011, pet. denied); Sw. Pharm., 408 S.W.3d at
562; Tex. Gov’t Code § 311.023(6).
Where a statute is ambiguous, the Court must give serious consideration to
the interpretation of an agency charged with its enforcement. Texas Citizens, 336
S.W.3d at 625. In Texas Citizens, the Supreme Court held:
We have never expressly adopted the Chevron or Skidmore doctrines for our consideration of a state agency’s construction of a statute, but we agree with the Commission that the analysis in which we engage is similar. In our “serious consideration” inquiry, we will generally uphold an agency’s interpretation of a statute it is charged by the Legislature with enforcing, “‘so long as the construction is reasonable and does not contradict the plain language of the statute.’”
Id. (citations omitted). Deference to the agency’s interpretation is particularly
important where, as here, the policies, rules and statutes in question concern a
29 matter within the core expertise of the agency. See Zimmer US, Inc. v. Combs, 368
S.W.3d 579, 586 (Tex. App.—Austin 2012, no pet.)
Southwest Pharmacy is also instructive. The plaintiff pharmacy providers
challenged HHSC rules pertaining to Medicaid pharmacy reimbursements. The
outcome of the dispute turned, in part, on construction of the phrase “medical
assistance” as defined in Government Code chapter 531, Human Resources Code
chapter 32, and the rules adopted thereunder. Sw. Pharm., 408 S.W.3d at 560-61.
In siding with HHSC, the court noted that the disputed statutory language must not
be read in isolation, but rather, must be analyzed “in the context of the statutes as
a whole.” Id. “We must consider the role of the provisions in the full Medicaid
statutory scheme and in . . . context. . . And we must construe the provisions in a
way that is consistent with their underlying purpose and the policies they are
intended to promote.” Id. at 561. The court further noted:
Even if we were to conclude that there is vagueness, ambiguity, or room for policy determinations in these statute and rules, we would conclude that HHSC's interpretation of the relevant code provisions and agency rules is reasonable, in harmony with the statutes and rules, and entitled to deference. We defer to the agency's interpretation unless it is plainly erroneous or inconsistent with the language of the statute or rule.. As the agency designated to administer Medicaid, HHSC is charged with overseeing a complex regulatory scheme, and deference to its construction is particularly important. An agency's construction does not have to be “the only-- or the best-- interpretation in order to warrant . . . deference.” Considering the entire statutory scheme, the
30 goals and policies behind it, and the legislative history and intent, we would conclude that HHSC's interpretation is reasonable, does not conflict with the provisions' language, and is entitled to deference.
Id. at 561-62 (emphasis added) (internal citations omitted). Here, the EC’s
interpretation of the meaning of ectopic eruption is reasonable, and is consistent
with Medicaid policy and applicable laws.
As explained in the AFO, the EC determined that “ectopic eruption” is a term
of art in the dental profession and should be interpreted for Medicaid just as it is
generally recognized in the field of dentistry, and consistent with the expert
opinions of Dr. Tadlock, Dr. Altenhoff and the Dr. Proffit textbook. The EC’s
interpretation of ectopic eruption is narrow, objective not subjective, and consistent
with Medicaid’s orthodontic policy of providing benefits to children with
dysfunctional severe handicapping malocclusions rather than providing benefits to
children who have solely cosmetic needs. If the EC did not correct the ALJ’s
erroneous interpretation of ectopic eruption, dental providers would be able to
apply a broad, subjective standard and use that subjective standard to qualify nearly
any patient regardless of need or Medicaid’s other limitations solely on the basis of
“ectopic eruption.” Such a scenario would fly in the face of Medicaid’s clear policy
of providing limited orthodontic benefits only for severe handicapping conditions
and not providing benefits for cosmetic reasons only.
The EC’s policy interpretation is also squarely within his core area of
31 expertise as the chief executive of the agency in charge of Texas Medicaid.
Therefore, it is entitled to deference from the Court. Texas Citizens, 336 S.W. at
629; Sw. Pharm., 408 S.W.3d at 561-62; Garcia, 454 S.W.3d at 137. This proper
interpretation by the EC is the lynchpin of the modifications to the ALJs’ PFD, as
discussed infra.
II. The EC did not exceed his authority in entering the AFO and Antoine cannot establish otherwise.
Antoine cannot establish that the EC exceeded his authority in entering the
AFO. The standard of review for an abuse of discretion by a state agency is whether
the agency’s final decision: (1) ignores the factual record; (2) relies on facts not in
evidence; or (3) is not rationally connected to the factual record. City of El Paso, 883
S.W.2d at 184; State v. Pub. Util. Comm’n, 883 S.W.2d at 201; Heritage on the San
Gabriel v. Tex. Comm’n on Envt’l Quality, 393 S.W.3d 417, 423 (Tex. App.—Austin
2012, pet. denied), (quoting City of Waco v. Tex. Comm’n Envtl. Quality, 346
S.W.3d 781, 819-20 (Tex. App.—Austin 2011, pet. denied)).
The AFO is squarely based on the factual record from the SOAH hearing.
The AFO is 42 pages long and is replete with references to uncontested evidence.
App. A. Further, no reasonable argument can be made that the AFO relies on facts
not in evidence or that it is rationally unrelated to the evidence. In short, there is
no credible argument that the EC abused his discretion in rendering the AFO.
32 All of the EC’s modifications in the AFO were made to correct
misunderstandings and misapplications of Medicaid law and policy by the ALJs.
Substantial evidence exists to show the EC correctly maintained the payment hold,
and Antoine cannot present evidence to the contrary; therefore, the Court should
uphold the AFO.
A. The ALJs misunderstood and misapplied Texas Medicaid law and policy and the EC corrected the misunderstanding with a proper construction of law and policy.
The ALJs incorrectly concluded that OIG failed to present prima facie
evidence that is “credible, reliable, or verifiable, or that has indicia of reliability”
that Antoine engaged in fraud or willful misrepresentation in filing its requests for
prior authorization and claims for payment with Texas Medicaid. Consequently
the ALJs recommended that the EC order the OIG to lift the payment hold in its
entirety. See PFD proposed FoF Nos. 48-50, at pp. 40-41, A.R. at 1234- 35.
The ALJs’ incorrect findings, conclusions, and ultimate recommendation
rested on their erroneous determination that Texas Medicaid adopted a “special”
definition of the term “ectopic eruption” that is subjective and broader than the
meaning of the phrase in the general practice of dentistry. This is clearly at odds
with the EC’s interpretation that ectopic eruption means the same thing in Texas
Medicaid as it does in the general practice of dentistry. In making this
determination, the ALJs ignored the plain language of the policy and the testimony
33 of the only witnesses qualified to testify what Texas Medicaid policy means. The
ALJs’ mistaken construction of ectopic eruption effectively destroys the
limitations of Texas law and Medicaid policy which restrict orthodontia to
children who suffer from a “severe handicapping malocclusion.” 25 Tex. Admin.
Code § 33.71.
Rather than concluding that the definition of ectopic eruption is subjective,
the ALJs should have adopted the agency’s own construction, as presented by
agency staff witnesses and by the State’s testifying expert.33 The record presented
by the State shows that the TMPPM’s instruction regarding ectopic eruption is not
vague and is consistent with the widely recognized understanding of ectopic
eruption. See Vol.1, 236:3-15, A.R. at 2047 (Dr. Tadlock testifying that the
definition of ectopic eruption is learned at every dental school and in every
orthodontic program in the country); 34 see also Vol. 2 at 84:23-24, A.R. at 2135
33 Dr. Tadlock is the only board-certified orthodontist who testified in this case. He is one of only eight directors nationally on the American Board of Orthodontists and is the incoming Chair of the ABO clinical committee, which administers the clinical exam to orthodontic residents nationally. Vol. 1, at 133:10-134:20, A.R. at 1944-45.
34 Dr. Tadlock reviewed nearly 1,300 articles discussing “ectopic eruption.” Vol. 1, at 152:1- 154:11, A.R. at 1963-65. As Dr. Tadlock noted, “The bottom line is this, there are no references to teeth that are rotated or tipped. There are -- ectopic eruption in every article is a tooth that is away from, it is out of place, it is in the wrong place. Not most of them, many of -- not most of them, all of them.” Id. at 153:1-6 (emphasis added), A.R. at 1864; see also 154:4-11, A.R. at 1965 (“But in every case, they are teeth that are out of the position, they are not here in turn; they are out, they are somewhere else. That's the definition of ectopic eruption that existed that started in 1938 or somewhere before then. It has existed in its same form since then, up to '87 when Dr. Proffit wrote its eruption in the wrong place, and that definition has not changed.”) (emphasis added).
34 (where Antoine’s expert Dr. Orr acknowledged that “ectopic” means “out of
place,” and that this meaning is found “in medicine all over.”).
The administrative record reflects HHSC’s long-standing requirement that
medical and dental terms be interpreted for Medicaid purposes just as those terms
are construed for non-Medicaid patients. Ex. R-14, (2008 TMPPM) at § 1.2.5, at
App. G; Ex. R-15 (2009 TMPPM), at § 1.4.5, at App. F; Vol. 1, 93:2-9, 94:16-
23, 111:11-14, A.R. at 1904-05; Vol. 3, 193:5-194:1, 241:5-11, 249:11-250:19,
A.R. at 2480-81, 2528, 2536-37.
Dr. Tadlock’s testimony that ectopic eruption is generally understood
within the dental/orthodontic profession as a “tooth that is out of place,” is not
only supported by the medical literature and the testimony of the State’s Medicaid
policy witness, Dr. Altenhoff, it is also the only competent expert testimony of
record. See generally Dr. Tadlock’s testimony at Vol. 1, at 152:1-154:11, A.R. at
1963-65; see also Vol. 3, 240:22-241:4, A.R. at 2527-28 (testimony that Dr.
Altenhoff is the person most knowledgeable about Medicaid policy), and Vol. 3,
174:19-175:7 (Antoine’s dentist Dr. Kanaan acknowledging that Dr. Altenhoff is
the expert on what Medicaid covers and does not cover), A.R. at 2461-62.35
The ALJs’ error in disregarding the testimony of Drs. Tadlock and
35 When asked by the ALJ if conditions would qualify as ectopic eruption after the January 2012 clarifying amendment, Dr. Kanaan answered: “You would need to ask Dr. Altenhoff.” Vol. 3, 174:19-175:4, A.R. at 2461-62.
35 Altenhoff was magnified because they misconstrued what Antoine’s orthodontist,
Dr. Kanaan actually said. The ALJs incorrectly asserted that Dr. Kanaan
concluded that Patients 36, 37, 42, 43, and 47 each presented a “severe
handicapping malocclusion.” See PFD at 26-27, A.R. at 1220-21. This statement
is not supported by the evidentiary record. Of these patients, the only ones for
which Dr. Kanaan made such statement were Patients 36 and 47. Vol. 3, at 149:3-
4, A.R. at 2436 (describing Patient 36 as a “100 percent dysfunctional
handicapping case”); Vol. 3, at 161:23-162:6, A.R. at 2448-49 (opining that
Patient 47 presented “dental necessity, medical necessity, hundred -- hundred
percent handicap malocclusion”). For the other patients, Dr. Kanaan merely stated
that the patient, in his opinion, needed orthodontic treatment. Vol. 3, at 156:16-19
(Patient 37) (answering “100 percent, 120 percent” when asked patient had a “true
orthodontic need”), A.R. at 2443; Vol. 3, at 155:1-6 (Patient 42) (answering
“correct, hundred percent” when asked if case was an example of “true orthodontic
need”), A.R. at 2442; Vol. 3, at 159:12-16 (Patient 43) (agreeing that the patient
had a “true orthodontic need for braces”), A.R. at 2446. This distinction is more
than a semantic one, as the standard for Medicaid coverage is “severe
handicapping malocclusion” and not merely “true orthodontic need.” See 25 Tex.
Admin. Code § 33.71.
Taken together, testimony and evidence presented at the administrative
36 hearing, coupled with deference that should be given to the EC’s interpretation of
Texas Medicaid policy, 36 illustrate that: (a) the ALJ’s incorrectly interpreted and
applied Medicaid policy; (b) the EC was authorized to correct misapplications of
law and policy; and (c) the EC did not exceeded his authority in correcting the ALJs.
As a result, the Court should affirm the AFO.
1. The rules of statutory construction govern questions of agency policy and administrative rules.
In determining the proper scope and limitations of Medicaid policy, and the
administrative rules of HHSC implementing Medicaid policy, the Court is guided
by the rules governing statutory construction. See Boswell v. Brazos Electric
Power, 910 S.W.2d 593, 599-600 (Tex. App.—Fort Worth 1995, writ denied);
Tex. Gov’t Code § 311.002(4).
In construing a statute, the primary objective is to ascertain and give effect
to the intent of the legislature. Cont’l Cas. Ins. Co. v. Functional Restoration
Assocs., 19 S.W.3d 393, 402 (Tex. 2000) (citing Liberty Mut. Ins. Co. v. Garrison
Contractors, Inc., 966 S.W.2d 482, 484 (Tex.1998)); Texas Citizens, 336 S.W.3d
at 624; Tex. Gov’t Code § 312.005. In so doing, courts look first to the plain and
common meaning of the statute's words. See Tex. Gov’t Code § 311.005;
Fitzgerald v. Advanced Spine Fixation Sys., Inc., 996 S.W.2d 864, 865 (Tex.1999).
36 Discussed infra.
37 Courts will consider the entire statute, not simply the disputed portions. State v.
Terrell, 588 S.W.2d 784, 786 (Tex.1979). Each provision must be construed in the
context of the entire statute of which it is a part. Bridgestone/Firestone, Inc. v.
Glyn-Jones, 878 S.W.2d 132, 133 (Tex.1994)
The Code Construction Act, Government Code chapter 311, provides
additional guidelines for statutory interpretation. For instance, words and phrases
should be read in context, not in isolation. Tex. Gov’t Code § 311.011(a). Words
and phrases that have acquired a technical or particular meaning shall be construed
accordingly. Tex. Gov’t Code § 311.011(b). The entire statute is intended to be
effective. Tex. Gov’t Code § 311.021(2). A just and reasonable result is intended;
one that is feasible of execution. Tex. Gov’t Code §§ 311.021(3), (4). The public
interest is favored over any private interest. Tex. Gov’t Code § 311.021(5).
In construing a statute a court may consider: (1) the object sought to be
obtained; (2) the consequences of a particular construction; and (3) an agency’s
construction of a statute that is committed to the agency for enforcement. Tex.
Gov’t Code §§ 311.023(1), (5), (6).
2. The ALJs ignored statutes, rules, and evidence and made fundamental errors in interpreting and applying Texas Medicaid policy. The misapplications were properly corrected by the EC.
The EC acted within his authority and sound discretion when he applied
principles of statutory construction and declined to adopt the ALJs’
38 misconstruction of Texas Medicaid policy. The EC corrected fundamental errors
in the ALJs’ interpretation of Texas Medicaid Policy.
First, the ALJs erroneously determined that the TMPPM includes a special
definition of ectopic eruption that is capable of different interpretations in different
circumstances. Under this interpretation, the ALJs found that Antoine’s scoring of
twisted and rotated teeth as ectopic was acceptable. However twisted and rotated
teeth are normal and do not impair function. See, e.g., note 34, supra. Therefore,
the ALJs’ misinterpretation runs afoul of the plain language of Texas Medicaid
policy, as set forth in the TMPPM and in HHSC rules, which clearly states the
Medicaid orthodontia benefit is limited to cases where the patient presents a
“severe handicapping malocclusion.” 25 Tex. Admin. Code § 33.71; Ex. R-15 at
§ 19.19, at App. F. Furthermore, the ALJs’ erroneous interpretation violates a
fundamental requirement that law and agency policy should be construed
consistently with their plain language. Texas Citizens, 336 S.W.3d at 624. It was
therefore proper for the EC to correct these misinterpretations.
Second, the specific instruction regarding “ectopic eruption” should have
been construed by the ALJs in the overall context of Medicaid’s limited
orthodontia benefit policy. Tex. Gov’t Code § 311.011(a). Instead, the ALJs
examined the ectopic eruption discussion in the TMPPM in isolation, and without
regard to the remainder of the TMPPM or overall objectives of Texas Medicaid
39 policy. In fact, the ALJs applied an interpretation of the meaning of ectopic
eruption that was not only contrary to plain language of Medicaid law and policy,
it was also fundamentally at odds with the overall objective of the policy. The
ALJs’ liberal interpretation of the meaning of ectopic eruption 37 was erroneous
because it violated the TMPPM’s clear direction that providers should be
conservative in scoring the HLD. See, e.g., Ex. R-15 at § 19.21, at App. F.
(“Providers should be conservative in scoring. Liberal scoring will not be helpful
in the evaluation and approval of the case.”). 38 Moreover, the ALJs’ construction
of “ectopic eruption” in isolation from the overall context of Medicaid’s policy
also violated the requirement to consider the disputed portions of the policy within
the policy as a whole. Bridgestone/Firestone, Inc. v. Glyn-Jones, 878 S.W.2d 132,
133 (Tex. 1994).
The ALJs’ construction of Medicaid policy violated several additional
37 The absurdity of the ALJs’ construction is illustrated by Antoine’s expert, Dr. Orr, who testified that in his broad reading of the Manual’s instruction “. . . to me, semantically it has a limitless interpretation as far as the recognition by competent dentists of teeth out of position.” Vol. 2, 148:23-149:2, A.R. at 2199-2200. The ALJs’ interpretation of the instruction renders the word “unusual” in the instruction meaningless, a result that violates canons of statutory construction. See, e.g., TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432, 439 (Tex. 2011). As Dr. Tadlock testified, based on medical literature, nearly 80 percent of the population has teeth that are crooked to some degree, and therefore there is nothing “unusual” for teeth to erupt in a manner that is not straight or ideal. Vol. 1, at 157, A.R. at 1968. 38 The idea that HHSC would eviscerate Medicaid orthodontic policy and benefit limitations by promulgating a new and more liberal definition of a widely understood term –– is, at best counterintuitive.
40 tenets of statutory construction in the Code Construction Act:
• The ALJs ignored the meaning of ectopic eruption generally understood in the dental profession, in violation of Tex. Gov’t Code § 311.011(b) (terms that have acquired technical or particular meanings shall be construed accordingly); • The ALJs’ broad interpretation of ectopic eruption rendered the limiting language in State regulations (e.g., 25 Tex. Admin. Code § 33.71) and in Medicaid policy (e.g., Ex. R-15, at § 19.19, at App. F) ineffective, in violation of Tex. Gov’t Code § 311.021(2) (the entire statute is presumed to be effective); • The ALJs’ interpretation leads to an “ectopic eruption in the eye of the beholder” standard, which is absurd given scarce Medicaid resources and HHSC statements regarding the limited nature of the orthodontic benefit. Opening the definition to the subjective interpretation of providers (“if the provider says its ectopic eruption, then it’s ectopic eruption”) also deprives Medicaid policy makers of their statutory and regulatory responsibility for defining the scope of the benefit. Thus the ALJs’ interpretation violates Tex. Gov’t Code § 311.021(3) (a just and reasonable result is intended), and Tex. Gov’t Code § 311.021(4) (a result feasible of execution is intended); • The ALJs’ construction favors only the private pecuniary interests of unscrupulous providers, at the expense of taxpayers and truly eligible Medicaid recipients. Thus, the ALJs’ interpretation violates Tex. Gov’t Code § 311.021(5) (public interest is favored over any private interest); • The ALJs failed to consider the purposes of Medicaid policy: their construction does not advance the goal of preserving scarce Medicaid dollars by limiting orthodontic reimbursements to cases of severe handicapping malocclusion. Thus, the ALJs’ interpretation violates Tex. Gov’t Code § 311.023(1) (a court considers the object sought to be obtained by the statute); and • The ALJs failed to consider the consequences of their interpretation. Under their interpretation, any provider’s prior authorization request for comprehensive orthodontia will be approved, so long as the provider scores the HLD with a 26 or greater – without regard to the true condition of the patient. This has far reaching implications for the Medicaid program, particularly in light of the ALJs’ acknowledgement (proposed FoF No. 25) that HHSC’s Medicaid claims processing contractor, TMHP, abrogated its responsibility to review clinical data submitted with prior authorization requests. The ALJs’ interpretation violates Tex. Gov’t Code § 311.023(5) (a court considers the consequence of a particular construction).
41 It was therefore proper for the EC to correct these misinterpretations.
Finally, the ALJs’ interpretation of the Medicaid meaning of ectopic
eruption was contrary to HHSC’s long-held and consistent construction of the
phrase. OIG presented evidence during the hearing that a January 2012
amendment to the TMPPM language addressing ectopic eruption was intended to
clarify the Medicaid program’s long-standing interpretation, not to implement a
substantive change in policy. See testimony of Dr. Linda Altenhoff, Vol, 1 at 93:2-
9, 94:16-23, A.R. at 1904-05; and testimony of Deputy Inspector General for
Enforcement, Vol. 3 at 193:5-194:1, 294:21-23, A.R. at 2480-81, 2581. This
testimony from Medicaid program officials was uncontroverted.
Nevertheless, the ALJs erroneously concluded that the January 2012
language was intended to effect a substantive change to the “definition” of ectopic
eruption. In the district court, Antoine characterized the ALJs’ determinations
regarding the effect of the January 2012 language change as a finding of
adjudicative fact that the EC was not allowed to alter. Antoine is wrong. Whether
the language change in the TMPPM was intended to be substantive or clarifying
is a question of law, committed to the discretion of the EC. Sw. Pharm. Solutions,
408 S.W.3d at 561-62; Boswell, 910 S.W.2d at 599-600. It was therefore proper
for the EC to correct these misinterpretations.
42 B. Substantial evidence exists to show that Antoine committed fraud or made willful misrepresentations necessary to maintain the payment hold. The EC properly corrected the ALJs’ errors, and Antoine cannot establish that the EC exceeded his authority.
The ALJs erroneously determined that there exists a special definition for
ectopic eruption under the Medicaid Program—a definition that, as described
supra, is inconsistent with Medicaid’s limited orthodontic benefit. As a result, they
found that none of the HLD scoresheets Antoine submitted included false
statements or misrepresentations. Consequently, they wrongly concluded that
Antoine’s conduct was neither fraudulent nor willfully misrepresentative.
In reaching this conclusion, the ALJs ignored substantial evidence of
Antoine’s conduct, disregarded the testimony of the OIG’s expert, and
impermissibly created “expert” opinions from the testimony of Antoine’s Drs.
Nazari and Kanaan.
Antoine did not address the issue of substantial evidence in its district court
brief. Accordingly, Antoine waived any argument that the AFO is not supported
by substantial evidence. See Akin, 2015 WL 1611803, at *3 n.1. This alone should
be enough to affirm the AFO. Nevertheless, the State will show that the AFO is
fully supported by substantial evidence, and in so showing will establish that the
district court erred in reversing the AFO.
43 1. Providers have a duty to know and follow law and policy.
In reaching their flawed interpretation of Medicaid policy, the ALJs ignored
Antoine’s duty, as a matter of law, to understand and comply with Medicaid
requirements, standards, and procedures. See Heckler v. Community Health Servs.,
467 U.S. 51, 63-65 (1984). Heckler involved the Government’s recovery of
payments incorrectly made to a Medicare provider, who contended the
Government was estopped from recovering because the provider relied on
authorization by a fiscal intermediary. Id. at 53, 60. The Heckler Court rejected
the availability of estoppel. Heckler found that the provider had lost no legal right
because it was never entitled to the money in the first place. Id. at 61-62.39 Heckler
also found that the provider had a duty to know the provisions under which it
received government funds. Id. at 64. The Court noted:
Justice Holmes wrote: “Men must turn square corners when they deal with the Government” (citing Rock Island, A. & L.R. Co. v. United States, 254 U.S. 141, 143 (1920)). This observation has its greatest force when a private party seeks to spend the Government’s money. Protections of the public fisc requires that those who seek public funds act with scrupulous regard for the requirements of law; respondent could expect no less than to be held to the most demanding standards in its quest for public funds. This is consistent with the general rule that those who deal with the Government are expected to know the law and may not rely on the conduct of Government agents contrary to law.
39 See also Personal Care Products, Inc. v. Hawkins, 635 F. 3d 155 (5th Cir. 2001) (noting that providers have no property interest in Medicaid reimbursement receivables).
44 Id. at 63; see also N. Mem’l Med. Ctr. v. Gomez, 59 F. 3d 735, 739 (8th Cir. 1995)
(participants in the Medicaid program have a “duty to familiarize themselves with
the legal requirements” of Medicaid procedures). Providers may not claim after
getting caught in a lie that they interpreted a term in a manner that contradicts
Medicaid policy, federal and state law, and the industry-wide understanding of the
term. Likewise, Antoine’s misrepresentations were not excused and should not
have been given credit by the ALJs. The EC was well within his authority to
correct the ALJs misapplication and misinterpretations of Medicaid policy.
Therefore, the Court should affirm the AFO.
2. Dr. Kanaan’s scoring pattern shows, at a minimum, he acted with conscious disregard or reckless indifference to the truth or falsity of his representations of patient conditions.
Dr. Kanaan’s scoring pattern shows substantial and reliable evidence of
fraud: he scored 27 of the 63 patients in the sample, and of those 27 patients, Dr.
Kanaan scored 23 (85%) as having the same eight teeth ectopic. Vol. 3 at 43-70,
A.R. at 2330-57. Ex. P-64.01 through P-64.63; R-49, Tadlock summary, at A.R.
1097-98, App. I. The rate of occurrence of ectopic eruption in the cases scored by
Dr. Kanaan flies in the face of expert testimony from disinterested
orthodontists that, according to the scientific literature, ectopic eruption is rare
and the incidence of even one tooth ectopic occurs only in between 1.5 and 9
45 percent of the population. 40 The chances that 85% of Dr. Kanaan’s patients would
each have the same eight ectopic teeth, when less than 10% percent of the
population has even one ectopic tooth, is infinitesimal. See Dr. Tadlock’s
testimony, Vol. 1 at 174-175, A.R. at 1985-86. Although the ALJs made passing
note of Dr. Kanaan’s scoring pattern, they failed to draw any inferences from this
conduct, nor did they explain how this evidence relates to the OIG’s burden to
continue the payment hold.41See 42 C.F.R. § 455.2 (a Medicaid agency may
receive credible allegations of fraud from any source, including “patterns
identified through provider audits.”).42
Additionally, OIG presented reliable evidence that Antoine submitted
fraudulently scored HLD scoresheets for 61 of the 63 patients by falsely
40 Dr. Kanaan testified the ectopic eruption is so rare that he has never treated a private-pay patient for a single ectopically-erupted tooth. Vol. 3 at 96:6-9, A.R. at 2383. Yet, he also testified that he does not diagnose Medicaid and private-pay patients differently. Id. at 17:22-25, A.R. at 2304. Dr. Kanaan even testified that the very same mouth that has ectopically-erupted teeth for Medicaid purposes is a prime example – the very example he uses on his other practice’s website– of crowding. Vol. 3 at 20:25-21:1, A.R. at 2307-08 (the photo on his website is an example of crowding), 21:5-20, A.R. at 2308 (explaining that the photo is of ADC’s Medicaid patient), 25:5- 25:8, A.R. at 2312 (stating that he scored this patient as ectopic). 41 None of the patients in the sample were eligible for Medicaid-covered comprehensive orthodontics without Antoine’s score for ectopic eruption: excluding those ectopic eruption scores, Antoine’s sample HLD scores ranged from 0 to 19. See R-49, Tadlock summary, at A.R. 1097-98, App. I. Assuming arguendo that each of these patients had two instances of the rare condition of anterior ectopic eruption, they still would not have been eligible for Medicaid- covered comprehensive orthodontics, as they could not achieve the qualifying score of 26. 42 The evidentiary burden on OIG in this proceeding is very low. The evidence must have “indicia of reliability.” In other words, it is reliable unless rebutted and shown to be immaterial, untrue, inaccurate or unreliable
46 representing that each of these 61 patients had six or more ectopically-erupted teeth.
See R-49, Tadlock summary, at A.R. 1097-98, App. I. In light of the commonly
understood meaning of ectopic eruption as established by the testimony of Dr.
Tadlock and Dr. Altenhoff, the egregiousness of Antoine’s scoring pattern shows
reliable prima facie evidence of fraud or willful misrepresentations and satisfied
the OIG’s burden to maintain the payment hold. Tex. Gov’t Code § 531.102(g)(2).
3. The ALJs compounded their errors by relying on “experts” who misunderstood and misapplied Texas Medicaid policy.
The ALJs expressly declined to rely on Antoine’s proffered experts, Orr and
Ornish, for their determinations regarding ectopic eruption. PFD at 28, A.R. at
1222. Instead the ALJs attempted to refute Dr. Tadlock’s expert testimony by
citing to the testimony of Drs. Nazari and Kanaan. However, Antoine did not
proffer or qualify either Dr. Nazari or Dr. Kanaan as an expert, and the ALJs erred
in considering them experts.43 See also Petitioner’s Expert Designations (listing
43 The State objected to Dr. Kanaan being treated as an expert witness. Vol. 3 at 128:2-5, A.R. at 2415. The ALJs abused their discretion when they considered Dr. Kanaan’s testimony as an expert. Vol. 3 at 128:6-16 (ALJ: “Well he [Dr. Kanaan] may not have been offered as an expert but he certainly is qualified as an expert as much as any other.”). The ALJs, sua sponte designated Dr. Kanaan as an expert. Vol. 3 at 129: 3-5, 19-22, A.R. at 2416 (allowing a treatise to be shown to Dr. Kanaan to show “what the expert relied on” and “showing in part what Dr. Kanaan relied upon in forming his expert opinions”). Nor did Antoine ever offer or qualify Dr. Kanaan as an expert witness. Because of the ALJs’ abuse of discretion in designating a party opponent as an expert, the EC acted well within his discretion in correcting any proposed findings or conclusions that were predicated on the ALJs’ erroneous ruling. As for Dr. Nazari, Antoine never offered him as an expert. Vol. 4, A.R. 2633-2794. The ALJs in their PFD, again sua sponte, designated Dr. Nazari as an expert. See PFD at 28 (discussing Dr.
47 Dr. Orr and Dr. Ornish), A.R. at 356-74. The ALJs also failed to note Dr. Nazari’s
testimony that he learned to score the HLD index “for Medicaid” from Dr. Orr.
Vol. 4 at 137:17-25, A.R. at 2765.44 Thus, even though the ALJs putatively did not
rely on Orr and Ornish, their reliance on Dr. Nazari is misplaced because his
opinions are derivative of Dr. Orr, who incorrectly opined that Texas Medicaid
adopted a special liberal definition of ectopic eruption.45 The ALJs therefore erred
by relying on providers, for their interpretation of Medicaid policy; and by
disregarding the testimony of Medicaid policy witnesses and qualified experts. See
Sw. Pharm., 408 S.W.3d at 561-62; Wood v. Tex. Comm’n Envtl. Quality, 2015
WL 1089492, at *6.
Nazari’s testimony as an expert), A.R. at 1222. The EC correctly modified any findings or conclusions relying on the ALJs’ erroneous designation of Dr. Nazari as an “expert.” 44 Dr. Nazari testified the methodology he applied for ectopic eruption was to include any teeth that were "rotated, the slanted leaning teeth" based on what he learned from Dr. Orr a decade prior. Vol. 4, at 102:22-103:4, 138:18-23, A.R. at 2730-31, 2766 (including "twisted or turned or crooked" teeth). This description, comports with neither the generally-accepted scientific understanding of the term "ectopic eruption" nor the instruction of the TMPPM which refers to "an unusual pattern of eruption." 45 The ALJs summarily, and incorrectly, stated that the HLD scores of Dr. Orr and Dr. Ornish, , were “generally similar” to Antoine’s scores and that their testimony was “cumulative” of the testimony of Drs. Nazari and Kanaan; the ALJs asserted that they did not rely upon the testimony of either Dr. Orr or Dr. Ornish. PFD at 28, A.R. at 1222. OIG objected to this supposed cursory treatment of Antoine’s experts for two reasons. First, the evidence shows Dr. Nazari’s understanding of HLD scoresheets was directly based on training he received from Dr. Orr. Vol. 4, at 137-38, A.R. at 2765-66; See also Respondent’s Closing Brief at 13, 33-37, A.R. at 1001, 1021-22. Second, it is factually incorrect to conclude that Dr. Ornish’s scores were “generally similar” to Antoine’s– in fact, Dr. Ornish, the only expert orthodontist retained by Antoine, scored 13 of the 63 Antoine patients as having an HLD score less than 26. Thus, Antoine’s own expert opined that nearly 21 percent of the Antoine patients did not qualify for Medicaid based on the HLD score.
48 III. Every modification made in the EC’s AFO is supported by substantial evidence and Antoine cannot establish otherwise.
For each modification that he made to the ALJs’ PFD, the EC met the
requirements to support his changes to the PFD in his AFO. See e.g., Flores v.
Emps. Ret. Sys. of Tex., 74 S.W.3d 532, 540 (Tex. App.—Austin 2002, pet.
denied); Pierce v. Tex. Racing Comm’n, 212 S.W.3d 745, 755 (Tex. App.—Austin
2006, pet. denied); see also Dunn, 2003 WL 22721659, at *1. There must be a
rational connection between an underlying agency policy and the altered finding
of fact or conclusion of law. See, e.g., Heritage on the San Gabriel, 393 S.W.3d at
440-4; State v. Mid-South Pavers, Inc., 246 S.W.3d 711, 728 (Tex. App.–Austin
2007, pet. denied); Levy v. Tex. State Bd. of Medical Exam’rs, 966 S.W.2d 813,
816 (Tex. App.–Austin 1998, no pet.).
In the district court, Antoine specifically claimed that the EC erred in
changing Findings of Fact 45-50 and Conclusion of Law 13. Because Antoine
limited its arguments to those findings of fact and conclusion of law, it has waived
argument as to any other changes the EC made to the AFO. Each of the EC’s
modifications to the contested findings and conclusions was authorized by law and
fully supported by substantial evidence in the record.
A. Finding of Fact No. 45
Finding of Fact No. 45 reads:
In reviewing the 63 ADC patient files in the statistically valid
49 random sample, Dr. Tadlock applied the definition of ectopic eruption that is generally recognized within the dental profession and scored the patients as instructed by the Manuals. Dr. Tadlock properly applied Medicaid policy.
As proposed by the ALJs, proposed FoF No. 45 read: “Dr. Tadlock did not
apply the Manual’s definition of ectopic eruption in scoring the HLD index for the
63 patients.” A.R. at 1234.
The EC was authorized to modify proposed FoF No. 45 because it addresses
a mixed question of fact and law, and is therefore a “legislative finding.” 46 See
Sanchez, 229 S.W.3d at 515-16; Dunn, 2003 WL 22721659, at *3 (quoting
McCown & Leo, at 68-69); Montemayor, 2003 WL 2140151, *8.
The ALJs’ proposed FoF No. 45 was a legislative finding because it was
expressly premised on the erroneous and impermissible interpretation that Texas
Medicaid policy incorporates a special definition for ectopic eruption. The ALJs’
proposed FoF No. 45 had two incorrect assumptions: (1) Medicaid had a special
definition for ectopic eruption; and (2) Dr. Tadlock failed to apply Medicaid
policy. Neither assumption is accurate.
The EC fully explained the reasons for his modification of FoF No. 45 in
his AFO. See App. A, at pp. 21-23, A.R. at 1764-66. This explanation provides
the substantial evidence needed to support the AFO. Antoine cannot establish a
46 See McCown & Leo, supra note 31.
50 lack of substantial evidence on the part of the EC, and consequently, the Court
should affirm the AFO.
B. Finding of Fact No. 46.
Finding of Fact No. 46 reads:
Despite the SOAH ALJs finding Dr. Nazari’s testimony to be credible, Dr. Nazari did not properly follow Medicaid policy in his identification of ectopic eruptions; the overwhelming evidence of the consistent pattern of inflated HLD scores submitted by ADC establishes prima facie evidence that is reliable, relevant and material that ADC‘s misrepresentations of medical necessity constitute willful misrepresentations.
As proposed by the ALJs FoF No. 46 stated: Dr. Nazari was a credible
witness and properly utilized the Manuals’ definition in scoring the HLD index.
Finding of Fact No. 46 is a legislative finding because it is founded on the
(erroneous) presumption that Texas Medicaid policy incorporates a special
definition for ectopic eruption. The ALJs’ proposed finding had two components:
(1) Medicaid had a special definition for ectopic eruption; and (2) Dr. Nazari
properly followed Medicaid policy in scoring his patients. Neither element is
accurate.
The EC modified the ALJs’ proposed FoF No. 46 because the ALJs relied
on the faulty proposition that Medicaid adopted a special definition for ectopic
eruption. Further, Dr. Nazari’s testimony reveals that he did not properly apply
Medicaid policy to the scoring of his patients. Vol. 4, at 103:13-16, 104:1-4, 145:9-
51 10, A.R. at 2731-32, 2773, where Dr. Nazari testified that orthodontics for
Medicaid patients is different than orthodontics for non- Medicaid patients.47
Further, Dr. Nazari was unable to define a “severe handicapping malocclusion.”
Id., at 144:17-145:6, A.R. at 2772-73. The EC fully explained his reasons for
modifying FoF No. 46. See App. A, at pp. 23-24, A.R. at 1766-67. This provides
the substantial evidence needed to support the AFO. Antoine cannot establish a
lack of substantial evidence on the part of the EC, and consequently, the Court
C. Finding of Fact No. 47.
Finding of Fact No. 47 reads:
Despite the SOAH ALJs finding Dr. Kanaan’s testimony to be credible, Dr. Kanaan did not properly follow Medicaid policy in his identification of ectopic eruptions; the overwhelming evidence of the consistent pattern of inflated HLD scores submitted by ADC establishes prima facie evidence that is reliable, relevant and material that ADC‘s misrepresentations of medical necessity constitute willful misrepresentations. As proposed by the ALJs FoF No. 23 stated: Wael Kanaan, D.D.S. an
orthodontist who worked with ADC was a credible witness and properly utilized
the Manuals’ definition of ectopic eruption in scoring the HLD index.
Finding of Fact No. 47 is a legislative finding because it is founded on the
47 In this regard, Dr. Nazari’s testimony differed from Dr. Kanaan’s. Dr. Kanaan testified that Medicaid patients and non-Medicaid patients should be diagnosed and treated to the same standard; yet, in practice he did not follow that guidance. See supra note 40.
52 (erroneous) presumption that Texas Medicaid policy incorporates a special
definition for ectopic eruption. The ALJs’ proposed finding had two components:
(1) Medicaid had a special definition for ectopic eruption; and (2) Dr. Kanaan
properly followed Medicaid policy in scoring his patients. Neither element is
First, the EC corrected the ALJs’ error of law regarding Medicaid policy.
Then, he appropriately applied the law to the facts in the record. In their PFD, the
ALJs acknowledged that Dr. Kanaan scored 23 of 27 patients exactly the same
way—with the same eight teeth being scored as ectopic in all 23 patients. PFD at
p.25, A.R. at 1219. Although they recognized this pattern by Dr. Kanaan, the ALJs
failed to correctly apply the law to the facts. Dr. Kanaan’s approach to Medicaid
patients, at the very least, indicates that Dr. Kanaan was reckless in his scoring, or
indifferent to the actual standards for qualifying a Medicaid patient. Dr. Kanaan’s
scoring 23 out of 27 patients exactly the same way constitutes prima facie evidence
that he acted with the requisite scienter to commit fraud or willful
misrepresentations. See Tex. Hum. Res. Code § 36.0011(b), defining Culpable
Mental State:
A person acts knowingly with respect to information if the person:
(1) has knowledge of the information; (2) acts with conscious indifference to the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the
53 information. Tex. Hum. Res. Code § 36.0011(a).
In his AFO the EC fully explained the reasons for his changes to FoF No.
47. See App. A, at pp. 24-26, A.R. at 1767-69. This provides the substantial
evidence needed to support the AFO. Antoine cannot establish a lack of
substantial evidence on the part of the EC, and consequently, the Court should
affirm the AFO.
D. Finding of Fact No. 48.
Finding of Fact No. 48 reads:
HHSC-OIG presented evidence that is credible, reliable, and verified, and that has indicia of reliability when analyzed consistently with Texas law and Medicaid policy, that ADC knowingly incorrectly scored the HLD index on orthodontic prior approval requests submitted to Texas Medicaid. As proposed by the ALJs, FoF No. 48 stated: There is no evidence that is
credible, reliable, or verifiable, or that has indicia of reliability, that ADC
incorrectly scored the HLD Index to obtain Texas Medicaid benefits for patients
or to obtain Texas Medicaid payments.
The EC was authorized to change FoF No. 48 because it is a mixed finding
of fact and law. The finding incorporates two components: (1) a statement
regarding whether Antoine properly scored the HLD index (“There is no evidence
. . . that ADC incorrectly scored the HLD . . .”); and (2) a statement regarding
Antoine’s intent (“. . . to obtain Texas Medicaid benefits for parents or to obtain
54 Texas Medicaid benefits.”). As to both components, the ALJs’ proposed finding
reflected a misunderstanding of: (a) Texas Medicaid policy; (b) the OIG’s burden
of proof in a payment hold proceeding; and (c) the standard for proving scienter
In contravention of HHSC policy, the ALJs erroneously determined that
Texas Medicaid adopted a liberal interpretation of Medicaid policy with respect
to ascertaining whether a patient exhibits ectopic eruption. Upon accepting the
“anything goes” standard propounded by Drs. Orr, Nazari and Kanaan, the ALJs
then found no error, much less a willful error in Antoine’s scoring. The lynch-pin
to this finding was the ALJs’ misunderstanding, and misapplication, of the limits
of Texas Medicaid’s orthodontia policy. The ALJs compounded their error by
misapplying Texas law: specifically, the ALJs misapplied the OIG’s burden of
proof at the proceeding, and they ignored the TMFPA standard for scienter of
conscious indifference or reckless disregard. See Tex. Hum. Res. Code §
36.0011(a).
At the payment hold hearing, the OIG bore the burden of presenting prima
facie evidence of fraud or willful misconduct. Prima facie evidence is “evidence
that, until its effect is overcome by other evidence, will suffice as proof of a fact
in issue.” Rehak Creative Servs. v. Witt, 404 S.W.3d 716, 726 (Tex. App.—
Houston [l4th Dist.] 2013, pet. denied). The OIG satisfied its burden by presenting
55 evidence of Antoine’s scoring pattern for the HLD scoresheets. See R-49, Tadlock
summary, at A.R. 1097-98, App. I. Section 36.0011 of the TMFPA, as noted
supra, defines the culpable mental state the State must establish to prove unlawful
acts. The State must show the person acted with knowledge of the truth or falsity
of information; or with conscious indifference to the truth or falsity of the
information; or with reckless disregard of the truth or falsity. Tex. Gov’t Code §
36.0011(a). Importantly, the State is not required to show the person’s specific
intent to commit an unlawful act. Id., § 36.0011(b).
Therefore, in correctly applying Medicaid policy and Texas law to the
evidence, the EC was fully authorized to correct the ALJs’ erroneous finding: (1)
that there was not credible, reliable, verified evidence with indicia of reliability
that Antoine incorrectly scored HLD indices; (2) that there was no evidence
Antoine did so for the purpose of obtaining Medicaid benefits.
As required by law, the EC fully explained the rationale for his changes. See
App. A, at pp. 26-28, A.R. at 1769-71. This explanation provides the substantial
evidence needed to support the AFO. Antoine cannot establish a lack of
substantial evidence on the part of the EC, and consequently, the Court should
E. Finding of Fact No. 49.
Finding of Fact No. 49 reads:
56 HHSC-OIG presented prima facie evidence that is credible, reliable, and verified, and that has indicia of reliability when analyzed consistently with Texas law and Medicaid policy, that [Antoine] committed fraud or willful misrepresentations to Texas Medicaid.
As proposed by the ALJs, FoF No. 49 stated: There is no evidence that is credible,
reliable, or verifiable, or that has indicia of reliability, that [Antoine] committed
fraud or engaged in willful misrepresentation with respect to the 63 [Antoine]
patients in this case.
The EC was authorized to change FoF No. 49 because it is a mixed finding
of fact and law. The ALJs’ proposed finding incorporated their misunderstanding
of Medicaid policy, and misapplication of Texas law, to the evidence. The EC
explained the reasons for his changes to FoF No. 49. See App. A, at pp. 28-30,
A.R. at 1771-73. This explanation provides the substantial evidence needed to
support the AFO. Antoine cannot establish a lack of substantial evidence on the
part of the EC, and consequently, the Court should affirm the AFO.
F. Finding of Fact No. 50.
Finding of Fact No. 50 reads:
HHSC-OIG presented prima facie evidence that is credible, reliable, and verified, and that has indicia of reliability when analyzed consistently with Texas law and Medicaid policy, that ADC committed fraud or wilful misrepresentations in filing requests for prior authorization with TMHP for a substantial majority of patients in the OIG audit sample.
As proposed by the ALJs, FoF No. 50 stated: There is no evidence that is credible,
57 reliable, or verifiable, or that has indicia of reliability, that ADC committed fraud
or misrepresentation in filing requests for prior authorization with TMHP for the
63 patients at issue in this case.
The EC was authorized to change FoF No. 50 because it is a mixed finding
of fact and law. The ALJs’ proposed finding incorporated their misunderstanding
of Medicaid policy, and misapplication of Texas law, to the evidence. As with FoF
No. 49, the EC explained the rationale for his changes. See App. A, at pp. 30-31,
A.R. at 1773-74. This explanation provides the substantial evidence needed to
support the AFO. Antoine cannot establish a lack of substantial evidence on the
part of the EC, and consequently, t the Court should affirm the AFO.
G. Conclusion of Law No. 13.
Conclusion of Law No. 13 in the AFO reads:
HHSC-OIG should maintain the payment hold against ADC for alleged fraud or willful misrepresentation, and program violations. Tex. Gov’t Code § 531.102(g) (2011); 42 CFR § 455.23 (2011); Tex. Hum. Res. Code § 32.091(c) (2003); 1Tex. Admin. Code §§ 371.1703(b)(3), and (b)(5), 371.1617(a)(1)(A)-(C), (I), (K), (2)(A), (5)(A), (5)(G) (2005).
As proposed by the ALJs, CoL No. 13 stated: HHSC-OIG lacks authority to
maintain the payment hold against ADC for alleged fraud or misrepresentation.
Tex. Gov’t Code § 531.102(g) (2011); 42 CFR § 455.23 (2011); Tex. Hum. Res.
Code § 32.091(c) (2003); 1 Tex. Admin. Code §§371.1703(b)(3),
371.1617(a)(1)(A)-(C) (2005).)
58 The EC was authorized to change CoL No. 13 because it was a pure question
of law committed to the discretion of the agency. Further, to the extent that CoL
No. 13 was actually a recommendation from the ALJs, and not a true conclusion
of law, the EC was fully authorized to modify it. See Granek v. Texas State Bd. of
Med. Exam'rs, 172 S.W.3d 761, 781 (Tex. App.—Austin 2005, no pet.); Akin,
2015 WL 1611803, *5; see also Pierce v. Tex. Racing Comm’n, 212 S.W.3d at
754 n.7 (“We need not decide, however, whether the ALJ had authority to
recommend a penalty in a racing commission case because, regardless of whether
the ALJ's conclusion of law was authorized, the Commission was statutorily
authorized to modify or reject it.” (citing Tex. Gov't Code § 2001.058(e))).
As required by the APA and black letter Texas law, the EC fully
explained the reasons for his change to CoL No. 13. See App. A, at pp. 39-40, A.R.
at 1782-83. This explanation provides the substantial evidence needed to support
the AFO. Antoine cannot establish a lack of substantial evidence on the part of the
EC, and consequently, the Court should affirm the AFO.
PRAYER
WHEREFORE, the State prays that the Court find that the AFO is fully
supported by substantial evidence, and the EC did not exceed his authority in
entering the AFO. The State respectfully prays that this Court reverse the
honorable district court and affirm the EC’s AFO in all respects.
59 Respectfully submitted,
OFFICE OF THE ATTORNEY GENERAL
CHARLES E. ROY First Assistant Attorney General
JAMES E. DAVIS Deputy Attorney General for Civil Litigation
/s/ Raymond C. Winter RAYMOND C. WINTER Chief, Civil Medicaid Fraud Division State Bar No. 21791950 Phone: (512) 936-1709 Fax: (512) 370-9477 raymond.winter@texasattorneygeneral.gov REYNOLDS B. BRISSENDEN State Bar No. 24056969 reynolds.brissenden@texasattorneygeneral.gov Phone: (512) 936-2158 NOAH REINSTEIN State Bar No. 24089769 noah.reinstein@texasattorneygeneral.gov Phone: (512) 463-3457
Assistant Attorneys General Office of the Attorney General of Texas Civil Medicaid Fraud Division P.O. Box 12548, Capitol Station Austin, Texas 78711-2548
ATTORNEYS FOR TEXAS HEALTH AND HUMAN SERVICES COMMISSION AND OFFICE OF THE INSPECTOR GENERAL
60 CERTIFICATE OF COMPLIANCE
I certify pursuant to Tex. R. App. P. 9.4(i) that this Brief, excluding the: caption, identity of parties and counsel, statement regarding oral argument, table of contents, index of authorities, statement of the case, statement of issues presented, signature, proof of service, certification, certificate of compliance, and appendix has 14,450 words. This Brief was prepared using Microsoft Word 2010 and I have relied on the word count from that program.
/s/ Raymond C. Winter Raymond C. Winter
CERTIFICATE OF SERVICE I certify that I have on this the 9th day of November, 2015, served copies of this Appellant’s Brief to the following:
Jason Ray J.A. “Tony” Canales Riggs & Ray, PC Canales & Simonson, PC 506 W. 14th Street, Suite A 2601 Morgan Avenue Austin, Texas 78701 P.O. Box 5624 jray@r-alaw.com Corpus Christi, Texas 78465 tonycanales@canalessimonson.com
61 INDEX OF APPENDIX
APPENDIX A Amended Final Order
APPENDIX B Medicaid.gov Website, Statistics
APPENDIX C Excerpts from Tex. Medicaid and CHIP in Perspective, 10th Ed., Feb. 2015
APPENDIX D 2011 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX E 2010 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX F 2009 Tex. Medicaid Provider Procedures Manual - Excerpts
APPENDIX G 2008 Tex. Medicaid Provider Procedures Manual – Excerpts
APPENDIX H Exhibit R-51. Prevalence of malocclusion and orthodontic treatment need in children and adolescents in Bogota, Colombia. An epidemiological study related to different states of dental development. Birgit Thilander, 2001, European J. of Orthodontics.
APPENDIX I Spreadsheet of dental scores submitted by Antoine
APPENDIX J Exhibit R-88. HHSC-OIG’s Proffer of Rebuttal Testimony from Dr. Linda Altenhoff
62 Append¡x A II32
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on2the2lim2form2is2 trueD2urteD2nd2HmpleteF”A2@emphsis2ddedAF2 roposed2pop2xoF2PW2is2 lso2misleding2euse2it2 omits2the2ft2tht2hrF2xzri2 is2 not2n2orthodontistF2hereforeD2the2ixeutive2gommissioner2is2 fully2uthorized2 to2 orret2 this2 tehnil2 error2 @y2 omissionA2 in2 pop2xoF2 PWF2 exF2 qov’t2 gode §2 PHHIFHSV@eA@QAF2 he2yer2evts2lso2erred2to2the2extent2tht2they2relied2on2the2l~9{rlz92Gvgen2 pmily2 hentl2deisionD2 prtiulrlyD2 polc2 PWD2 QID2 nd2QQD2 for2their2understnding2 of2the2 sope2nd2 limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2 on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2 wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2@}ov’t2gode2 §2PHHlFHSV@eA@PAF2 qiven2the2issues2 in2 this2 pyment2hold2proeedingD2nd2the2requirements2 of2exs2 lw2nd2wediid2poliyD2 there2is2 therefore22rtionl2 onnetion2etween2 exs2 lw2 nd2 the2 ltered2 finding2 of2ftF2 eeD2 eF2gFD2 reritge2 on2 the2 n2 qriel2 romeowners2essoF2 vF2 2 giD2QWQ2FFQd2t2 RRHERIY2tte2vF2 IIGlidEouth2versD2 lnFD2 PRT2FFQd2t2 UPVY2v€l{}G2 vF2 exF2 tte2f’2 F2 of2wedF2ixm2’rsD2 WTT2FFPd2t2 VITF2 hrF2 ivns2onluded2tht2 in2 ll2 TQ2sesF2 the2linil2 reords2did2 not2support2the2 soring2on2the2lEsvh2sore2sheets2sumitted2with2the2prior2utlIori9GFFtion2 requests2 euse2of2the2 sore2ssigned2to2the2etopi2eruption2tegoryF2hrF2 ivns2 did2not2 testify2in2this2mtterF2
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001760 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
en2urte2understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2 is2 ritilly2 importnt2to2the2outome2of2this2 disputeF2he2fundmentl2llegtion2 rought2y2the2snspetor2qenerl2is2 tht2ehg2hs2sumitted2lims2for2e2nd2for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2 finder2of2ft2does2not2understnd2 the2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 of2wediid2poliy2nd2the2 ltered2 finding2of2ftD2 whih2urtely2 reflets2tht2poliyF2eeD2eF2gFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2FFQd2t2RRHERIY2tte2vF2 widEouth2versD2snFD2 PRT2FFQd2t2UPVY2 vevy2vF2 exF2tte2felF2 of2wedF2ixm2’rsD2 WTT2FFPd2t2VITF2 he2 lnguge2 in2 the2 wnuls2 provided2 instrutions2 to2 dentists2 nd2 orthodontists2 to2 sore2 etopi2 eruption2 onsistently2 with2 the2 stndrds2 for2 etopi2eruption2tht2re2generlly2reognized2in2the2dentl2professionF2 @he2 yGl~‘s2 evts’2 proposed2pop2xoF2 RI2 sttedX2 he2 lnguge2in2 the2 wnuls2 provided2t2 t9e9finitiHtz2 fetopi2eruption2solely2for2use2in2soring2the2rvh2index2to2 tjuliGjIGor2pymentFA2
eson2for2ghngeX2 pinding2of2pt2xoF2RI2 finding2ddresses22mixed2question2of2lw2nd2ft2nd2is 2 “legisltive2 findingF42 he2 ixeutive2 gommissioner2hs2 omplete2 disretion2 to2 82 modify2the2proposed2findingF2 exF2 hep9t2Hfviensing2 egultion2vF2 hompsonD2 PHIQ2 v2 QUWIRVTD2t2 BT2@“‘en2geny2enjoys2omplete2disretion2in2modifying2 n2GvFl9s2 findings2nd2onlusions2when2those2findings2nd2onlusions2retlet 2 lk2of2understnding2or2mispplition2of2the2existing2lwsD2rulesD2 or2poliiesG”2 @quoting2mith2vF2wontemyorD2PHHQ2 v2 PIRHISWID2t2BPTEPU2@emphsis2ddedlAY2 exF2qov‘t2gode2§2PHHlFFHSV@eA@IAF2 he2ixeutive2 gommissioner2modifies2roposed2pp2xoF2 RI2 for2 two2 resonsF2 pirstD2 the2 ww’s2 disussion2 of2 etopi2 eruption2 is2 n2 instrutionD2 not 2 definitionF2 eeD2 eFgFD2 FFD2 olF2 I2 t2 lHQXVElP2 @terms2 in2 the2 etopi2 eruption2 instrution2re2 not2defined2ut2re2orded2their2plin2 nd2ordinry2mening2in2 the2inglish2lngugeAY2FFFFD2 olF2 l2 t2 llli2 lPElR2@providers2must2understnd2the2 mnul2 y2 virtue2 of2 their2 professionl2 triningAF2 his2 error2 reflets 2 misinterprettion2of2lw2nd2poliy2y2the2 yer2evtsF2ee2exF2 qov’t2gode §2 PHHlFHSV@A@lAY2 hompsonD2 PHIQ2 v2 QUWIRVTF2 t2 BTY2 outhwest2 hrntD2 RHV2 FFQd2t2SSUESVF2 eondD2 the2 proposed2finding2erroneously2 suggests2 tht2 it2 ws2exs2 wediid2 poliy2 to2 dopt2 2 distint2 “definition”2 of2etopi2 eruption2 in2 the2 ww2tht2 ditiered2 from2 etopi2 eruption2 s2 generlly2 understood2 within2 the2 dentl
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001761 professionF2he2 yer2elFts’2proposed2finding2would2violte2stte2nd2federl2lw2 euse2 retion2 of2 2 different2 set2 HI92 stndrds2 pplile2 only2 to2 wediid2 ptients2would2violte2oth2exs2nd2pederl2lwF2eeD2 eF2gFD2 I2 exF2edminF2gode §2 QSRFIIQI@hAY2see2 lso2 D2olF2 QD2 PSHXVEIWY2ixF2 EIR2@PHHV2wwAD2§2 IFPFSY2 ixF2 EIS2 @PHHW2 wwAD2 §2 IFRFS2 @“gompline2 with2 pederl2 vegisltionF2 eminderX2 ih2provider2 must2furnish2 overed2llGeliil2 servies2 in2 the2 sme2 mnnerD2to2the2sme2extentD2 nd2of2the2sme2qulity2s2servies2prHvi9e92to2other2 ptientsF2 ervies2 mde2ville2 to2 other2ptients2 must2e2 mde2ville2 to2 exs2 weliil2 lients2 if2 the2 servies2 re2 enefits2 of2the2 exs2 wediid2 rogrm4AF2end2in2 ftD2 ll2 pulished2poliy2douments2promulgted2y2rrg2 require2providers2to2 pply2the2 sme2stndrds2of2re2to2 wediid2ptients2 they2 pply2with2the2popultion2t2lrgeF2eeD2 eFgFD2 ixF2EITD2t2§2 IFTY2ixF2EISD2§2 IWFPF2 ther2thn2 impermissily2employing2 2 speil2 or2unique2definition2 of2etopi2 eruption2 solely2 for2 use2 in2 the2 wediid2ontextD2 rrg2 poliy2 mkers2 insted2 instruted2providers2 to2 use2their2 triningD2 edutionD2 experieneD2 nd2definitions2 generlly2 understood2 in2 the2 prtie2 of2 dentistry2 in2 qulifying2 nd2 treting2 wediid2ptients2nd2to2senGe2these2ptients2in2the2sme2mnner2s2other2ptientsF2 eeF2 eFgFD2 FFF2olF2 I2 t2 IHQXVEIP2@terms2in2the2etopi2eruption2instrution2re2not2 defined2 ut2 re2 orded2 their2 plin2 nd2 ordinry2 mening2 in2 the2 inglish2 lngugeAY2FFD2 olF2 l2 t2 lllX2 IPEIR2@providers2 must2understnd2the2 mnul2y2 virtue2of2their2professionl2triningAF2
he2yer2evt2 s2 lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyF2l~‘op2 PWD2 QID2 nd2QQD2for2their2 understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2 lw2nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHIFHS2V@eA@PAF2
en2urte2understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2 outome2of2this2 disputeF2he2fundmentl2llegtion2 is2 ritilly2 importnt2to2 the2 rought2y2the2snspetor2qenerl2is2 tht2ehg2hs2sumitted2lims2for2e2nd2for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2it“2 the2 finder2of2ft2 does2not2understnd2 the2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 of2wediid2poliy2nd2the2 ltered2 finding2of2ftD2 whih2urtely2 reflets2tht2poliyF2eeD2eF2gFF2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giF2QWQ2FFQd2t2RRHERIY2tte2vF2 wid~HzGth2versD2nFD2 PRT2FFQd2t2UPVY2 vevy2vF2 exF2tte2fdF2 ofllGselF2 ixm rsD2 WTT2FFPd2t2VITF2 ’2
he2wnul2did2 not2 ddress2 how2n2 orthodontist2 dignosed2 or2 treted 2 ptientD2ut2only2instruted2providers2to2sore2nterior2teeth2onsistently2with2 the2 generlly2 understood2 definition2 of2 etopi2 eruption2 in2 the2 orthodonti2 professionF
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001762 s’2 proposed2pop2xoF2RP2sttedX2 he2wnuls2did2not2ddress2how2 @he2yGEr2evt2 n2orthodontist2dignosed2or2treted22ptientD2 ut2only2defined2etopi2eruption2 for2 soring2 the2 rvh2sore2 sheet2 to2 determine2 2 exs2 wediid2ptient2 ’s2
eligiilityfor2orthodonti2tretmentFA2
eson2for2ghngeX2 roposed2pyp2xoF2RP2ddresses22mixed2question2of2ft2nd2lwD2nd2is2 therefore2 2soElled2“legisltive2 findingF42feuse2the2 yer2evts’2proposed2finding2ot2 ft2 numer2RP2 reflets2 2 misinterprettion2 nd2 gross2 mispplition2 of2exs2 wediid2poliyD2the2ixeutive2gommissioner2hs2omplete2disretion2to2 modify2 the2proposed2findingF2 exF2 hep’t2of2viensing282egultion2vF2 hompsonD2 PHIQ2 v2QUWIRVTD2 t2 BT2 @“9en2geny2enjoys2 omplete2 disretion2 in2 modifying2n2 evt9s2findings2nd2onlusions2when2those2findings2nd2onlusions2reflet22lk2 of2 understnding2 or2 mispplition2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mith2vF2 wontemyorD2PHHQ2 v2 PIRHISWID2t2BPTEPU2@emphsis2ddedAAY2 exF2@ov’t2gode2§2PH@AIFHSV@eA@IAF2 he2ixeutive2 gommissioner2modifies2roposed2 pop2xoF2 RP2 for2 two2resonsF2 p2irstD2 the2 ww’s2 disussion2 of2 etopi2 eruption2 is2 n2 instrutionD2 not 2 definitionF2his2error2reflets22misinterprettion2of2lw2nd2poliy2y2the2yer2 evtsF2ee2exF2qov‘t2gode2§2 PHHIFHSV@eA@IAY2 hompsonD2PHIQ2v2QUWIRVTD2t2 BTY2outhwest2hrntD2RHV2FFQd2t2SSUESVF2
eondD2 the2 proposed2 finding2erroneously2 suggests2tht2 it2 ws2exs2wediid2 poliy2 to2 dopt2 2 distint2 “definition”2 of2etopi2 eruption2 in2 the2 ww2tht2 differed2 from2 etopi2 eruption2 s2 generlly2 understood2 within2 the2 dentl2 professionF2he2yer2 evts’2proposed2finding2would2violte2stte2nd2federl2lw2 euse2 retion2 of22 different2 set2 of2 stndrds2 pplile2 only2 to2 wediid2 ptients2would2violte2oth2exs2nd2federl2lwF2eeD2eF2gFD2 l2 exF2edminF2gode §2 QSRFI2IQI@hAY2 see2lso2FF2olF2 QD2 PSHXVEIWY2ixF2EIR2@PHHV2wwAD2§2 IFPFSY2 ixF2 EIS2 @PHHW2 wwAD2 §2 IFRFS2 @“gompline2 with2 pederl2 vegisltionF2 eminderX2 ih2provider2 must2furnish2 overed2wediid2servies2 in2 the2 some2 mnnerD2to2the2sme2extentD2 nd2of2the2sme2qulity2s2servies2provided2to2other2 ptientsF2 ervies2 mde2ville2 to2 other2ptients2 must2e2 mde2ville2 to2 exs2 wediid2 lients2 the2 servies2 re2 enefits2 of2the2 exs2 wediid2 rogrm”AF2end2in2 ftD2 ll2 pulished2poliy2douments2promulgted2y2rrg2 require2 providers2to2 pply2the2 sme2stndrds2of2re2 to2 wediid2ptients2they2 pply2with2the2popultion2t2 lrgeF2 eeD2 eFgFD2 ixF2EITD2t2 §2 IFTY2 ixF2EISD2§2 IWFPF2 he2wnuls2didD2 in2 ftD2 instrut2providers2to2use2their2trining2nd2edution2in2 the2tretment2of2wediid2ptients2nd2to2tret2those2ptients2 in2the2sme2mnner2 s2 other2 ptientsF2 ixF2 EIS2 @PHHW2 wwAD2 §2 IFRFSF2 he2 ixeutive2 gommissioner2is2 therefore2uthorized2to2 orret2this2error2y2the2evtsF2 ee2exF2 @Iov‘t2gode2§2PHHIFHSV@eA@I‘2 AF2 @QA2@llowing2n2geny2to2hnge22ph2 to2orret2 errors2of2lw2or2poliy2or2 tehnil2errors2in22proposed2finding2of2ftAF
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001763 he2yer2elFts2lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2prtiulrlyD2 pop2PWD2 QID2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2 wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
en2urte2understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2 outome2of2this2 disputeF2 he2fundmentl2llegtion2 is2 ritilly2 importnt2to2the2 rought2y2the2snspetor2qenerl2is2 tht2ehg2hs2sumitted2lims2for2e2nd2for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2finder2of2ft2 does2not2understnd2 the2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 of2wediid2poliy2nd2the2 ltered2finding2of2ftD2 whih2urtely2 reflets2tht2poliyF2eeD2eFgFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2FFQd2t2RRHERIY2tte2vF2 widEouth2yersD2srtFD2 PRT2FFQd2t2UPVY2 vevy2vF2 exF2tte2f’2 fweGF2ixm2’rsD2 WTT2FFPd2t2VITF2 F2
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ivnsF2 efter2 reviewing2 the2 ptients’2 rvh2sore2 sheetsD2 hrF2 2 dlok2 found2 only2 one2 ptientD2tient2ISD2who2met2the2PTEpoint2thresholds2
sn2reviewing2the2TQ2 ehg2ptient2files2in2the2sttistilly2vlid2rndom2smpleD2 hrF2 dlok2 pplied2 the2 definition2 of2 etopi2 eruption2 tht2 is2 generlly2 reognized2within2the2dentl2profession2nd2sored2the2ptients2s2instruted2 y2the2wnulsF2hrF2dlok2properly2pplied2wediid2poliyF2 @he2 yer2evts‘2 proposed2IIop2 xoF2 RS2 sttedX2 hrF2 dlok2did2not2 pply2the2 etopi2eruption2in2soring2the2rvh2index2for2the2TQ2ehg2 llGnnls2 definition2of2 ’2
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eson2for2ghngeX2 roposed2finding2of2ft2numer2RS2ddresses22mixed2question2of2ft2nd2lwD2 nd2 is2 2 “legisltive2 findingF”2 he2 ixeutive2 gommissioner2 hs2 omplete2 disretion2to2modify2the2proposed2findingF2 exF2 hep’t2of2viensing282egultion2 vF2 hompsonD2 PHIQ2v2 QUWIRVTD2t2BT2@“en2geny2enjoys2omplete2disretion2 in2 modifying2 n2 evt9s2 findings2 nd2 onlusions2 when2 those2 findings2 nd2 onlusions2reflet22lk2of2understnding2or2mispplition2of2the2existing2lwsD2 2 fy2letter2dted2tnury2 ITD2 PHIRF2the2yer2Gvts2replied2to2the2osnspetor2@tenerl92s2 Fxeptions2 IEX‘2
nd2notified2the2ixeutive2gommissioner2tht2their2originl2proposed2finding2of2ft2numer2RR2should2e2 reused2 he2lEvxeutive2 gommissioner2dopts2the2 elEFls’2 reommendtions2regrding2revised2proposed2 lmding2of2ft2numer2RRF2
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001764 rulesD2or2poliiesF”92@quoting2mith2vF2wonteGnyorD2PHHQ2 v2PIFRHISWID2t2BPTEPU2 @emphsis2ddedAAY2exF2qov’t2gode2§2PHHI2FHSV@eA@lAF2 he2ixeutive2 gommissioner2modifies2roposed2pop2xoF2 RS2 for2 two2resonsF2 pirstF2 the2 ww’s2 disussion2 of2 etopi2 eruption2 is2 n2 instrutionD2 not 2 definitionF2his2error2reflets22misinterprettion2of2lw2nd2poliy2y2the2yer2 evtsF2ee2exF2qov”t2gode2§2 PHHIFHSV@eA@lAY2hompsonD2PHIQ2 v2QUWIRVTD2t2 BTY2outhwest2hrmFD2RHV2FFQd2t2SSUESVF2
eondD2 the2 proposed2 finding2erroneously2 suggests2 tht2 it2 ws2exs2wediid2 poliy2 to2 dopt22 distint2 “definition”2 of2etopi2 eruption2 in2 the2 ww2tht2 differed2 fiom2 etopi2 eruption2 s2 generlly2 understood2 within2 the2 dentl2 professionF2he2yer2 evts92proposed2finding2would2violte2stte2nd2federl2lw2 euse2 retion2 of22 different2 set2 of2 stndrds2 pplile2 only2 to2 wediid2 ptients2would2violte2oth2exs2nd2federl2lwF2eeD2 eF2gFD2 I2 exF2edminF2gode §2 QSRFIlQl@hAY2see2lso2 FFD2olF2 QD2 PSHXVEIWY2ixF2 EIR2@PHHV2wwAF2§2 IFPFSY2 ixF2 EIS2 @PHHW2 wwAD2 §2 IFRFS2 @“gompline2 with2 pederl2 vegisltionF2 eminderX2ih2provider2 must2furnish2 overed2wediid2servies2 in2 the2 sme2 mnnerD2to2the2sme2extentD2 nd2of2tlze2 sme2qulity2s2servies2provided2to2other2 ptientsF2 ervies2 mde2ville2 to2 other2ptients2 must2e2 mde2 ville2 to2 exs2 wediid2 lients2 if2 the2 servies2 re2 enefits2 of2the2 exs2 wediid2 rogrm”AF2end2in2ftD2 ll2 pulished2poliy2douments2promulgted2y2rrg2 require2 providers2 to2 pply2the2 sme2stndrds2of2re2to2 wediid2ptients2 they2 pply2with2the2popultion2t2lrgeF2eeD2 eFgFD2 ixF2EITD2t2§2 IFTY2 EISD2§2 IWFPF2
elsoD2 the2 proposed2 finding2 misonstrues2 hrF2 dlol`92s2 testimonyF2 sn2 ftD2 hrF2 9l4dlok’s2 testimony2 shows2 tht2 in2 his2 viewD2 the2 wnul‘s2 instrutions2 re2 onsistent2with2the2generlly2understood2definition2of2etopi2eruptionF2FFD2olF2 lD2 PHPIPIEPHQXIHF2his2error2reflets22misinterprettion2of2 lw2nd2poliy2y2the2 yer2evFssD2 2 misinterprettion2 tht2 resulted2 in2 misonstruing2 hrF2 dlok’s2 testimonyF2exF2qov’t2gode2§2PHHlFHSV@eA@lAF2 he2yer2evls2lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pop2PWD2 QID2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2of2exs2 lw2nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 qov’t2gode2§2PHHIFHSV@eA@PAF2
en2urte2understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2 outome2of2this2 disputeF2he2fundmentl2llegtion2 is2 ritilly2 importnt2to2 the2 rought2y2the2snspetor2qenerl2is2 tht2ehg2hs2sumitted2lims2for2e2nd2for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2tinder2of2ft2does2not2understnd2 the2 poliyF2 herel’oreD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2of2wediid2poliy2nd2the2 ltered2 finding2of2ftD2 whih2urtely
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001765 reflets2tht2poliyF2eeD2eFgFD2 reritge2on2the2n2 qriel2romeowners2essoF2 vF2 giD2QWQ2FFQd2t2RRHER|Y2tte2vF2 widEouth2oversD2InFD2 PRT2FFQd2t2 UPVY2 vevy2vF2 exF2tte2fdF2of2 wedF2ixm rsD2WTT2FFPd2t2VITF2 ’2
hespite2 the2yer2evts2finding2hrF2 xzri’s2 x2zri2did2not2properly2follow2wediid2poliy2testimony2 to2 e2redileD2 hrF2 in2his2identifition2of2etopi2 eruptionsY2 the2 overwhelming2evidene2of2the2 onsistent2 pttern2 of2inflted2 rvh2sores2 sumitted2 y2 ehg2estlishes2 prim2 fie2 evidene2 tht2 is2 relileD2 relevnt2 nd2 mteril2 tht2 ehg‘s2 misrepresenttions2 of2 medil2 neessity2onstitute2willful2misrepresenttionsF2 @he2yer2evts’2proposed2pp2xoF2RT2sttedX2hrF2xzri2 ws22redile2witness2 nd2properly2utilized2the2wnuls2 definition2in2soring2the2rvh2 ’2
indexFA2 eson2for2ghngeX2 roposed2pop2xoF2RT2ddresses22mixed2question2of2ft2 nd2lwD2ndD2s2suhD2is 2 soElled2 “legisltive2 findingF42 hereforeD2 the2 ixeutive2 gommissioner2 hs2 omplete2 disretion2 to2 modify2 itF2 exF2 hep9t2 of2viensing2 82egultion2 vF2 hompsonD2 PHIQ2v2QUWIRVTD2t2 BT2@“en2geny2enjoys2 omplete2disretion2in2 modifying2n2evt9s2findings2nd2onlusions2when2those2findings2 nd2onlusions2 reflet2 2lk2 of2understnding2 or2 mispplition2 of2the2 existing2 lwsD2 rulesD2 or2 poliiesF4’2 @quoting2 mith2 vF2 wontemyorD2 PHHQ2 v2PIRHISWID2 t2 BPTEPU2 @emphsis2ddedAAX2exF2qov’t2gode2§2PHHIFHSV@eA@lAF2 he2 ixeutive2 gommissioner2modifies2roposed2pHI‘2 xoF2 RT2 for2 two2 resonsF2 pirstD2 the2 9I‘ww’s2 disussion2 of2 etopi2 eruption2 is2 n2 instrutionD2 not 2 definitionF2 eeD2 eFgFD2 FFD2 olF2 l2 t2 IHQXVEIP2 @terms2 in2 the2 etopi2 eruption2 instrution2re2not2defined2ut2re2orded2their2 plin2 nd2ordinry2mening2in2 the2inglish2lngugeAY2 FFD2olF2 I2 t2 ll2IX2 IPEIR2 @providers2must2understnd2the2 mnul2 y2 virtue2 of2 their2 professionl2 triningAF2 his2 error2 reflets 2 misinterprettion2of2lw2nd2poliy2y2the2 yer2 evtsF2ee2exF2 qov’t2gode §2 82 PHHlFHSV@eA@lAY2 exF2 hep9t2of2viensing2 egultion2 vF2 hompsonD2 PHIQ2 v2 QUWIRVTD2t2BTY2outhwest2hrmFD2RHV2FFQd2t2SSUESVF2 eondD2 the2 proposed2 finding2erroneously2 suggests2 tht2 it2 ws2exs2wediid2 poliy2 to2 dopt2 2distint2 “definition”2 of2etopi2 differed2 from2 etopi2 eruption2 s2 generlly2 eruption2 in2 the2 ww2 tht2 understood2 within2 the2 dentl2 professionF2he2yesEEs2evts’2proposed2finding2would2 violte2stte2nd2federl2lw2 euse2 retion2 of2 2 different2 set2 of2stndrds2 pplile2 only2 to2 wediid2 ptients2would2violte2oth2exs2nd2federl2lwF2 eeF2 eFgFD2 I2 exF2edminF2gode §2 QSRFIlQl@hAX2 see2lso2 FD2 olF2 QD2 PSHXVEIWY2 ixF2 EIR2 @PHHV2wwAD2§2 IFPFSY2 ixF2 EIS2 @PHHW2 wwAD2 §2 IFRFS2 @“gompline2 with2 pederl2 vegisltionF2 eminderX2 ih2provider2must2fitrnish2 overed2wediid2 servies2 in2 the2 sme2 mnnerD2to2the2some2extentD2 nd2of2the2sme2qulity2s2 servies2provided2to2other2 ptientsF2 ervies2 mde2ville2 to2 other2 ptients2 rnust2 e2 mde2ville2 to
PQ
001766 exs2 wediid2 lients2 if2 the2 servies2 re2 enefits2 exs2 wediid2 of2the2 rogrG9nF4AF2 end2in2 ftD2 ll2 pulished2poliy2douments2 promulgted2y2rrg2 require2providers2 to2 pply2the2 sme2stndrds2 HI42re2 to2 wediid2ptients2 they2 pply2with2the2popultion2t2lrgeF2eeD2 eFgFD2 ixF2EITD2t2 IFTY2 ixF2EISD2 IWFPF2 §2 §2 woreoverD2ontrry2 to2 exs2 wediid2poliy2 requirements2 tht2 providers2 tret2 wediid2ptients2 to2 the2 sme2stndrd2 of2re2 s2 the2 generl2 popultionD2 hrF2 xzri2 testitied2 tht2 orthodontis2 for2 wediid2 ptients2 is2 different2 thn2 orthodontis2 for2 nonEwediid2 ptientsF2 FFD2 olF2 RD2 t2 IHQIIQEITD2 IHRXI—RD2 IRSXW—IHF2 purtherD2 hrF2 xzri2 ws2 unle2 to2 define2 2 “severe2 hndipping2 mlolusionF”2l’2 t2lRRXlUE2IRSXTF2his2testimony2reflets2 F2 thtD2though2hrF2xzri2 my2e2viewed2y2the2finder2of2ft2s2redileD2hrF2xzri2ws2unle2to2properly2 pply2exs2wediid2poliy2to2the2soring2of2ptientsF2 he2 yer2evts2lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pop2PWD2 QID2 nd2QQD2 for2their2understnding2 of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2 they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2 wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2qov’t2gode2 §2PHHlFHSV@eA@PAF2 he2proposed2finding2reflets22fundmentl2misunderstnding2nd2 mispplition2 of2exs2wediid2poliy2y2the2 yer2GvFlsF2 en2urte2 understnding2of2the2 sope2 nd2 limittions2 of2exs2 wediid2 poliyis2 ritilly2 importnt2 to2 the2 outome2of2this2 disputeF2 he2fundmentl2 llegtion2 rought2 y2the2 snspetor2 qenerl2is2 tht2ehg2hs2sumitted2lims2por2e2nd2for2reimursement2 tht2re2 not2uthorized2under2wediid2poliy2or2exs2lwF2 hese2 llegtions2 nnot2e2 properly2evluted2if2the2ft2finder2does2not2properly2interpret2nd2 pply22poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 ot2 wediid2poliy2 nd2the2 ltered2 finding2of2ftD2 whih2urtely2 reflets2 tht2 poliyF2eeD2eF2gFD2 Freritge2on2the2n2qriel2romeowners2 essoF2 vF2 2giD2QWQ2 FFQd2RIUD2 RRHERI2 @exF2 eppF—eustin2PHIPD2 pet2 deniedAY2 tte2 vF2 widEouth2 versD2InFF2 PRT2FFQd2UIID2UPV2@exF2eppF—eustin2PHHUD2 petF2 deniedAY2vevy2vF2 exF2 tte2felF2 ofllGledF2 ixm’2 rsD2 WTT2FFPd2VIQD2 VIT2@exF2 eppF—euslin2 IWWVD2 no2ptAF2 hespite2the2yer2evts2finding2hrF2 unn’s2testimony2to2 e2redileD2 hrF2 unn2 did2 not2 properly2 follow2 wediid2 poliy2 in2 his2 identifition2 of2 etopi2 eruptionsY2 the2 overwhelming2 evidene2 of2 the2 onsistent2 pttern2 of2 inflted2rvh2sores2sumitted2y2ehg2estlishes2prim2fie2 evidene2tht2 is2 relileD2 relevnt2 nd2mteril2 tht2ehg‘s2misrepresenttions2of2medil2 neessity2onstitute2willful2misrepresenttionsF2 @he2 yer2evts’2 proposed2 pop2 xoF2 PQ2 sttedX2 el2 unnD2 hFhFF2 n2 who2worked2with2ehg2ws22redile2witness2nd2properly2utilized’2 HrtlzH9orztz9st2 the2wnuls2 lefinition2ofetopi2eruption2in2soring2 the2rvh2indexFA ’2
PR
001767 eson2for2ghng2 eX2
roposed2pop2xoF2RU2 ddresses2 2 mixed2question2of2ft2 nd2lwD2 nd2is2 2 soE2 lld2“legisltive2 findingF“2hereforeD2the2ixeutive2gommissioner2hs2omplete2 disretion2to2modify2itF2 exF2 hep9t2of2viensing282egultion2vF2 hompsonD2 PHIQ2 v2QUWIRVTD2t2 BT2 @“‘en2geny2enjoys2 omplete2 disretion2 in2 modifying2n2 evt‘s2findings2nd2onlusions2when2those2findings2nd2onlusions2reflet22lk2 of2 understnding2 or2 mispplition2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mith2vF2 wontemyorD2PHHQ2v2PIRHISWID2t2BPTEPU2@emphsis2ddedAAY2 exF2qov’t2gode2§2PHHlFHSV@eA@lAF2 he2ixeutive2gommissioner2modifies2roposed2pop2xoF2RU2for2three2 resonsF2 pirstD2the2 ww’s2 disussion2 of2 etopi2 eruption2 is2 n2 instrutionD2 not 2 definitionF2 eeD2 eFgFD2 FFD2 olF2 l2 t2 IHQXVEIP2 @terms2 in2 the2 etopi2 eruption2 instrution2re2 not2defined2ut2re2 orded2their2plin2nd2ordinry2mening2in2 the2inglish2lngugeAY2FFD2olF2 I2 t2 lllX2 IPEIR2@providers2must2understnd2the2 mnul2 y2 virtue2 of2 their2 professionl2 triningAF2 his2 error2 reflets 2 misinterprettion2of2lw2nd2poliy2y2the2 yer2 evtsF2ee2exF2qov9t2gode §2 PH@AIFHSV@A@lAY2 hompsonD2PHIQ2 v2 QUWIRVTD2 t2 BTY2 outhwest2hrntD2 RHV2 FFQd2t2SSUESVF2 eondD2 the2 proposed2 finding2erroneously2 suggests2 tht2 it2 ws2exs2wediid2 poliy2 to2 dopt22 distint2 “definition”2 of2etopi2 eruption2 in2 the2 lG{w2 tht2 differed2 from2 etopi2 eruption2 s2 generlly2 understood2 within2 the2 dentl2 professionF2he2yGIIevls’2proposed2finding2would2violte2stte2nd2federl2lw2 euse2 retion2 of2 2 different2 set2 of2stndrds2 pplile2 only2 to2 wediid2 ptients2would2violte2oth2exs2nd2federl2lwF2eeF2 eFgFD2 I2 exF2edminF2gode §2 QSRFIIQl@hAY2see2lso2FD2olF2QD2 t2PSHXVEIWY2ixF2EIR2@PHHV2wwAD2§2 IFPFSY2 EIS2 @PHHW2 wwAD2 §2 IFRFS2 @“gompline2 with2 pederl2 vegisltionF2 eminderX2 ih2provider2must2furnish2 overed2wediid2servies2 in2 the2 sme2 mnnerD2 to2the2sme2extentD2 nd2of2the2sme2qulity2s2servies2provided2to2other2 ptientsF2 ervies2 mde2ville2 to2 other2ptients2 must2e2 mde2ville2 to2 exs2 wediid2 lients2 if2 the2 servies2 re2 enefits2 of2the2 exs2 wediid2 rogrm”AF2end2in2 ftD2 ll2 pulished2poliy2douments2promulgted2y2rsE{g2 require2 providers2to2 pply2the2 sme2stndrds2of2re2to2 wediid2ptients2they2 pply2with2the2popultion2t2lrgeF2eeD2 eFgFF2ixF2EITD2t2§2 lFTY2ixF2EISD2§2 IWFPF2 por2exmpleD2 hrF2 unn2testified2 tht2 the2 word2“hndipping”2 in2 the2 phrse2 “severe2 hndipping2mlolusion”2 mens2“extreme2 devition2 from2the2 normF”2 FFD2olF2QF2 t2 IHIXQEVF2 etD2 of2the2TQ2 ptients2 in2 the2sttistilly2 vlid2rndom2 smpleD2unn2greed2tht2of2his2ptients2he2sored2t2lest2seven2etopi2teeth2in2 eh2ptientD2 2rte2 of2IHH7F2ldFD2 WUXSEVF2his2testimony2rellets2thtD2 though2hrF2 unn2my2e2 viewed2 y2the2 finder2of2ft2 s2 redileD2 hrF2 unn2did2 not2 properly2pply2exs2wediid2poliy2to2the2soring2ofptientsF2
PS
Rs
001768 hirdF2hrF2 unn2sored2PQ2of2PU2ptients2 extly2the2sme2y—with2the2sme2 eight2 teeth2 eing2 sored2 s2 etopiF2 EVQY2 olF2 Q2 t2 RQEUHF2 he2 knowledged2 this2 undisputed2 evideneF2 phD2 t2 yer2 evFls2 PSF2 his2 evidene2 of2 hrF2 unn‘s2pttern2 oi‘2 soring2is2 prim2fie2 evidene2tht2 hrF2 unn2ted2with2 requisite2knowledge2under2the2wpeF2 rumF2esF2gode2§2 QTFHHll@AF2 he2 exF2 ixeutive2 gommissioner2 is2 uthorizedD2 thereforeD2 to2 orret2 the2 yer2evts‘2 errorF2exF2qov’t2gode2§P@A@AIFHSV@eA@IAF2
he2yer2evt2 s2lso2erred2to2the2extent2tht2 they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pop2PWD2 QID2 nd2 QQD2 por2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2 poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2 onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2 exs2lw2nd2 wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2qov’t2 gode2§2P@AHIFHSV@eA@PAF2 he2proposed2finding2reflets22fundmentl2 misunderstnding2nd2mispplition2 of2exs2lw2nd2wediid2poliy2 the2yGr2 y2 evtsF2en2urte2understnding2 of2the2sope2nd2limittions2of2exs2wediid2 poliy2is2 ritilly2importnt2to2the2 outome2 of2this2 disputeF2 he2fundmentl2 llegtion2 rought2 y2the2 snspetor2 qenerl2is2 tht2ehg2hs2sumitted2lims2for2e2 nd2for2reimursement2tht2re2 not2 uthorized2under2wediid2poliy2or2 exs2lwF2 hese2llegtions2nnot2e2 properly2evluted2if2the2ft2finder2does2not2 properly2interpret2nd2pply22poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 ot2 wediid2poliy2 nd2the2 ltered2 finding2 of2ftD2 whih2urtely2 reflets2 tht2 poliyF2eeF2 eFgFD2 reritge2on2the2n2qriel2 romeowners2essoF2 vF2 giD2QWQ2 FFQd2RIUD2 RRHERI2 @exF2 eppF—eustin2PHIPD2 pet2 deniedAY2 tte2 vF2 widEouth2 versD2InFF2 PRT2FFQd2UIID2UPV2@exF2eppF—eustin2 PHHUD2petF2 deniedAY2vevy2vF2 exF2 tte2fdF2HfwedF2ixm2’rsD2 WTT2 FFPd2VIQD2VIT2@exF2eppF—eustin2IWWVD2no2 petFAF2
rrgEysq2presented2 evidene2tht2 is2 redileD2 relileD2 nd2 tht2hs2indii2of2reliility2when2 verifiedD2 nd2 nlyzed2onsistently2with2exs2lw2nd2 wediid2poliyD2 tht2 ehg2 knowingly2inorretly2 sored2the2 rvh2 index2on2 orthodonti2prior2pprovl2requests2sumitted2 to2exs2wediidF2 @he2 yer2evts’2 proposed2 sE4op2 xoF2 RV2 sttedX2 here2 is2 no2 evidene2 tht2 is2 redileD2 relileD2 or2 verifileD2 or2 tht2 hs2 indii2 of2reliilityD2 tht2 ehg2 inorretly2sored2the2rvh2sndex2to2 otin2 exs2wediid2enefits2for2ptients2 or2to2otin2exs2llGelii92pymentsFA2 eson2for2ghngeX2 roposed2polc2 xoF2 RV2ddresses2 2mixed2question2 of2ft2 nd2lwD2 nd2is2 2soE2 lled2“legisltive2findingF”2 hereforeD2 the2ixeutive2gommissioner2hs2omplete2 82egultion2vF2 hompsonD2 PHIQ2 disretion2to2 modify2itF2 exF2 hep’t2G‘viensiizg2 v2QUWIRVTD2 t2 BT2 @“en2geny2enjoys2 omplete2 disretion2 in2 modifying2 n2
PT 9
001769 esFt9s2 findings2nd2onlusions2whenF2those2 findings2nd2onlusions2reflet22lk2 understnding2 or2 mispplition2 oi’2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 ol’2
@quoting2mith2vF2wontemyorD2PHHQ2sF2PlRHlSWlD2t2BPTEPU2@emphsis2 ddedAAY2 exF2qov’t2gode2§2PHHlFHSV@eA@lAF2 he2ixeutive2gommissioner2modifies2roposed2pol’2xoF2RV2euse2the2 yess2 ests2 misinterpreted2 nd2 mispplied2exs2lw2nd2wediid2 poliyF2 pirstD2 the2 proposed2finding2mispplies2lw2nd2wediid2poliy2y2stting2 tht2 there2 is2 no2 evidene2tht2ehg2inorretly2sored2the2rvh2indexF2sn2ftD2 the2evidene2 shows2 tht2the2rsh2sores2sumitted2y2hrsF2xzri2nd2unn2 were2inorret2euse2 of2their2interprettion2of2etopi2 eruptionF2 eeD2 eFgFF2 testimony2of2hrF2 dloek2t2 D2olF2 lD2 t2 IUQXQETY2 IURXTEIUSXIY2 lUTXlREPHY2 IUUXIEITY2see2lso2testimony2of2 hrF2xzriD2D2olF2RD2t2 IRRXIcEIRSXTY2nd2testimony2of2hrF2 unnD2D2olF2QD2 t2RQEUHF2he2totlity2of2the2evideneD2whih2inludes2the2 testimony2ot‘ehg‘2s2own2 witnessesD2 s2 well2s2 the2 snspetor2qenerl92s2 ft2 witnesses2nd2expertsD2 is2 muh2 more2thn2prim2fizieD2nd2is2 relevntD2 redile2nd2mterilF2ee2exF2rumF2esF2 gode2§2QPFHPWI@AF2 eondD2 the2 proposed2 finding2 is2 erroneous2 euse2 impliit2 in2 it2 re2 the2 ssumptions2tht2 the2 definition2of2etopi2 eruption2is2 wholly2open2to2 sujetive2 interprettionF2 nd2tht2exs2wediid2dopted224speil42definition2 of2etopi2 eruption2tht2 ws2more2lierl2 thn2 the2 generlly2epted2definition2 of2 etopi2 eruption2in2the2orthodonti2profession2@nd2ontrry2to2the2ww’s2 instrution2 to2 providers2 to2 e2 “onservtive”2 in2 their2 soringAF2 hese2 errors2 reflet2 niisinterprettions2nd2mispplitions2of2lw2nd2wediid2 poliy2y2the2 yess2 evtF2 hirdD2hrF2unn2sored2PQ2of2PU2ptients2extly2the2sme2y—with2 the2sme2 eight2teeth2 eing2 sored2 s2 etopiF2 EVQY2 olF2 Q2 t2 RQEUHF2 purtherD2 the2yer2 evts2knowledged2this2 undisputed2evideneF2phD2t2 PSF2 his2evidene2of2hrF2 unn’s2pttern2 of2soring2 is2 prim2fie2 evidene2tht2 hrF2 unn2 ted2with2 requisite2knowledge2under2the2 wpeF2exF2 rumF2esF2gode2 §2 QTFHHI2l@AF2 he2 ixeutive2 gommissioner2 is2 uthorizedD2 thereforeD2 to2 orret2 the2 yer2evts’2 errorF2exF2qov’t2gode2§2PHHlFHSV@A@lAF2
pinllyD2this2proposed2finding2reflets22further2mispplition2of2lw2 in2suggesting2 tht2the2snspetor2qenerl2ers2the2urden2of2proving2intent2 to2defrud2wediidF2 es2 the2 yess2evts2 knowledge2 in2 the2 nrrtive2 setion2 of2their2 phD2 the2 snspetor2qenerl2does2not2hve2the2urden2to2show2speifi2intent2to2 defrud2the2 wediid2progrm2to2 show2tht2 ehg2hs2 ommitted2n2unlwful2t2 under2the2 wpeF2ee2ph2t2 lSD2iting2definition2of2“knowingly”2t2setion2QTFHHI2I2 ofthe2 wpeY2 see2 lso2 gov2 xoF2 TD2 t2 pge2 RP2 of2 the2 ph2 @sme2 propositionAF2 xeverthelessD2 in2 proposed2pop2xoF2RVD2the2 yer2evts2write2 tht2 the2 snspetor2 qenerl2 tiled2 to2 present2 redileD2 relileD2 or2 veritile2 evidene2 tht2 ehg
PU
001770 inorretly2sored2 rvh2indies2“to2otin2exs2wediid2enefits2for2ptients2or2 to2otin2exs2wediid2 pymentsF”2 he2urden2on2the2snspetor2qenerl2is2 only2to2demonstrte2relevntD2redile2nd2 mteril2evidene2tht2ehg2knowingly2sumitted2sores2tht2overstted2the2hild‘s2 true2 onditionF2 exF2 rumF2 esF2 gode2 §2 QPFHPWl@AF2 hrsF2 unn2 nd2 xzri2 knowledge2 they2 pplied2 n2 interprettion2 of2 etopi2 eruption2 tht2 did2 not2 omport2with2wediid2poliyF2o2the2extent2the2yer2evts2ttempt2to2hold2the2 snspetor2qenerl2to2the2dditionl2urden2of2proving2intent2on2the2prt2of2ehg2to2 defrud2the2wediid2progrmD2proposed2pop2xoF2RV2is2erroneousF2 he2yer2evts2lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 por‘2 PWD2QID2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2 lw2nd2wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHlFHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 reflets2 2 fundmentl2 misunderstnding2 nd2 mispplition2of2exs2lw2nd2wediid2poliy2y2the2yer2evtsF2en2urte2 understnding2of2the2sope2nd2limittions2 of2exs2wediid2poliy2is2 ritilly2 importnt2to2 the2 outome2of2this2 disputeF2 hese2llegtions2 nnot2e2 properly2 evluted2 if2the2 tinder2 of2ft2 does2 not2 properly2 interpret2 nd2 pply2 2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2 ot2 wediid2 poliy2 nd2the2 ltered2 finding2 of2ftD2 whih2urtely2 reflets2 tht2 poliyF2eeD2eF2gFD2 reritge2on2the2n2qriel2roineowners2essoF2 vF2 giD2QWQ2 FFQd2RlUD2 RRHERI2 @exF2 eppF—eustin2PHIPD2 pet2 deniedAY2 tte2 vF2 wid~Huth2 versD2 InFD2 PRT2FFQd2Ul2lD2 UPV2@exF2eppF—eustin2PHHUD2petF2 deniedAY2vexy2vF2 exF2tte2felF2 Gw€TlF2ixm29rsD2 WTT2FFPd2VIQD2VIT2@exF2eppF—eustin2IWWVD2no2 petFAF2
rrg~ylq2presented2prim2fie2 evidene2 tht2 is2 redileD2 relileD2 nd2 verifiedD2 nd2tht2 hs2indii2 of2reliility2 when2nlyzed2onsistently2 with2 exs2 lw2 nd2 wediid2 poliyD2 tht2 ehg2ommitted2 frud2 or2 willful2 misrepresenttions2to2exs2wediidF2 @he2 yer2evts’2 proposed2po‘2 xoF2 RW2 sttedX2 here2 is2 no2 evidene2 tht2 is2 redileD2 relileD2 or2 verifileD2 or2 tht2 hs2 indii2 of2reliilityD2 tht2 ehg2 oGnmitl9edfi4ud2or2engged2in2 willful2 misrepresenttion2with2respet2to2 the2 TQ2 ehg2ptients2in2this2seFA2 eson2por2ghngeX2 roposed2polc2 xoF2RW2ddresses2 2mixed2question2of2ft2 nd2lwD2 nd2is2 2soE2 lled2“legisltive2findingF”2 hereforeD2the2ixeutive2gommissioner2hs2omplete2 o disretion2to2modi4l’y2itF2 exF2 hept2ofliensing282egultion2vF2 hompsonD2 PHIQ2 v2QUWIRVTD2 t2 BT2@49en2geny2 enjoys2 omplete2 disretion2 in2 modifying2 n2 PV
001771 evt‘s2findings2nd2onlusions2when2those2findings2nd2onlusions2 rellet22lk2 oi’2 understnding2 or2 mispplietion2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mitlz2vF2 wontemyorD2PHHQ2 v2PIRHISWID2t2BPTEPU2@emphsis2ddedAAY2 exF2qov’t2gode2§2PHHlFHSV@eA@lAF2 he2ixeutive2gommissioner2modifies2roposed2polc2xoF2RW2euse2the2 yer2 evss2misinterpreted2nd2mispplied2exs2lw2nd2wediid2poliyF2 pirstD2 the2 proposed2finding2mispplies2exs2lw2governing2the2snspetor2qenerl’s2urden2 of2proof2in2this2 seF2 es2noted2in2 gov2xoF2 IPD2to2mintin2the2pyment2holdD2the2 snspetor2 qenerl2 must2 only2 mke22prim2fie2 showing2 of2evidene2 tht2 is2 redileD2 relile2 or2 verifileD2 or2 tht2 hs2 indii2 of2reliility2 tht2 ehg2hs2 ommitted2frud2or2willful2misrepresenttions2in2this2seF2 he2 yer2evts42 determintion2 tht2 the2 snspetor2 qenerl2 presented2 “no2 evidene”2 on2 this2 issue2 is2 the2 result2 of2 the2 yer2evts’2 leglly2 erroneous2 interprettion2of2wediid2poliy2with2respet2to2the2definition2of2etopi2 eruptionF2 es2the2snspetor2qenerl2noted2in2his2ixeptionsD2the2yesEs2evs’2determintions2 tht2 the2 following2 re2 ll2 errors2 in2 the2 interprettion2 nd2 pplition2 of2exs2 wediid2poliy2nd2lwX2@IA2exs2wediid2“defined”2etopi2eruption2uniquely2 nd2 differently2 in2 the2 ww2thn2 the2 generlly2 epted2 definition2 in2 the2 orthodonti2 professionY2 @PA2 tht2 sid2 definition2 ws2wholly2 open2 to2 sujetive2 interprettionY2 nd2@QA2 tht2 the2 PHIP2 hnges2 to2 the2 lGw2“definition”2 were2 sustntive2rther2thn2lrifyingF2
purtherD2 the2 yesEs2 evts2 lso2 mispplied2 lw2 nd2 poliy2 to2 the2 following2 evideneD2 whih2 they2 themselves2 knowledgedX2 hrF2 unn2 sored2 PQ2 of2PU2 ptients2extly2the2sme2wy—Ewith2the2sme2eight2teeth2eing2sored2s2 etopiF2 EVQY2olF2 Q2 t2RQEUHF2his2evidene2of2hrF2unn’s2pttern2of2soring2is2 prim2 feie2evidene2tht2hrF2unn2ted2with2requisite2knowledge2under2 the2 wpeF2 exF2 sEEsumF2 esF2 gode2§2 QTFHHII@AF2he2ixeutive2gommissioner2is2 uthorizedD2 thereforeD2to2orret2the2yess2evts’2errorF2exF2qov’t2gode2 §2PHHlFHSV@eA@lAF2 he2yer2evs2 s2 lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2 pmily2 hentl2deisionD2 prtiulrlyD2 poil2 PWD2 QID2 nd2QQD2 for2their2 understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2 wediid2 poliyF2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2 PHHI2FHSV@eA@PAF2 §2 woreoverD2 the2 proposed2 finding2 reflets2 2 fundmentl2 misunderstnding2 nd2 mispplition2of2exs2lw2nd2wediid2poliy2y2the2yesEs2e9vtsF2en2urte2 understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2is2 ritilly2 importnt2to2the2 outome2of2this2 disputeF2 he2fundmentl2llegtion2rought2 y2 the2 snspetor2 qenerl2 is2 tht2 ehg2 hs2 sumitted2 lims2 for2 e2 nd2 for2 reimursement2tht2re2not2utltorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2deision2mker2does2not2 understnd
PW
001772 the2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2of2wediid2poliy2nd2the2modified2finding2of2ftD2 whih2urtely2 reflets2tht2poliyF2eeD2eF2gFD2 reritge2on2the2n2qriel2romeowners2essoF2vF2 giD2QWQ2FFQd2t2RRHERIY2tte2vF2 widEouth2versD2snFD2 PRT2FFQd2t2UPVY2 vevy2vF2 exF2tte2fzl2of2wedF2ixm rsF2WTT2FFPd2t2VITF2 ’2
rrgEysq2presented2prim2fie2 evidene2 tht2 is2 redileD2 relileD2 nd2 verifiedD2nd2tht2hs2indiei2 of2reliility2 when2nlyzed2onsistently2with2 exs2 lw2 nd2 wediid2 poliyD2 tht2 ehg2ommitted2 frud2 or2 willful2 misrepresenttions2in2filing2requests2for2prior2uthoriztion2with2 wr2for 2 sustntil2mjority2of2ptients2in2the2ysq2udit2smpleF2 @he2 yer2evts‘2 proposed2pop2xoF2 SH2 sttedX2 here2 is2 no2 evidene2 tht2 is2 redileD2 relileD2 or2 verifileD2 or2 tht2 hs2 indii2 of2reliilityD2 tht2 ehg2 ommitted2fitGl2or2misrepresenttion2 in2filing2requests2Gor2prior2uthoriztion2 with2wrfor2the2TQ2ptients2t2issue2in2this2seFA2 eson2for2ghngeX2 roposed2pop2xoF2 SH2 ddresses2 2mixed2question2of2ft2 nd2lwD2 nd2is2 2 so~2 lled2“legisltive2findingF42hereforeD2the2ixeutive2gommissioner2hs2omplete2 82 disretion2to2modify2itF2 exF2 hep9r2of2viensing2 egultion2vF2 hompsonD2 PHIQ2 v2QUWIRVTD2 t2 BT2 @“‘en2geny2enjoys2 omplete2 disretion2 in2 modifying2n2 evt9s2findings2nd2onlusions2when2those2findings2nd2onlusions2reflet2 2lk2 of2understnding2 or2 mispplition2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mith2vF2wontemyorD2PHHQ2 v2 PIRHISWIF2t2BPTEPU2@emphsis2ddedAAY2 exF2qov’t2gode2§2PHHlFySV@eA@lAF2 he2ixeutive2gommissioner2modifies2roposed2polc2 xoF2SH2euse2the2yer2 evts2misinterpreted2 nd2mispplied2exs2lw2nd2wediid2poliyF2 pirstD2 the2 proposed2finding2mispplies2exs2lw2governing2the2snspetor2qenerl’s2urden2 of2proof2in2this2 seF2es2noted2in2gov2xoF2 IPD2 to2mintin2the2pyment2holdD2the2 snspetor2 qenerl2 must2 only2 mke22prim2jie2 showing2of2evidene2 tht2 is2 redileD2 relile2 or2 verifileD2 or2 tht2 hs2 indii2 of2reliility2 tht2 ehg2 hs2 ommitted2frud2or2willful2misrepresenttions2in2this2seF2 he2 yer2evts’2 determintion2 tht2 the2 snspetor2 qenerl2 presented2 “no2 evidene”2 on2 this2 issue2 is2 the2 result2 of2the2 yesEs2 evts’2 leglly2 erroneous2 interprettion2of2wediid2poliy2with2respet2to2the2definition2of2etopi2eruptionF2 es2the2snspetor2qenerl2noted2in2his2ixeptionsD2the2 yer2 evt2s’2 determintions2 tht2the2 following2r2 ll2 errors2 in2 the2pplition2of2exs2wediid2 poliy2nd2 lwX2@IA2exs2wediid2“defined”2etopi2eruption2uniquely2nd2differently2 in2the2 ww2 thn2the2generlly2epted2definition2in2the2 orthodonti2professionY2 @PA2 tht2 sid2definition2ws2wholly2open2to2sujetive2interprettionY2 nd2 @QA2 tht2 the2 PHIP2hnges2to2the2wlGl2“definition”2were2sustntive2rther2thn2lrifyingF
QH
001773 purtherD2 hrF2 unn2sored2 PQ2 of2PU2ptients2 extly2 the2 sme2wyE—vvit2 the2 sme2eight2teeth2eing2sored2s2etopiF2—VQY2olF2Q2t2RQEUHF2he2yer2evts2 knowledged2 this2 undisputed2 evideneF2 phD2 t2 PSF2 his2 evidene2 of2 hrF2 unn’s2pttern2 of2soring2is2 prim2pie2 evidene2tht2 hrF2 unn2ted2 with2 requisite2knowledge2under2the2wpeF2exF2rumF2esF2gode2 QTFHHI2l@AF2 he2 §2 ixeutive2 gommissioner2 is2 uthorizedD2 thereforeD2 to2 orret2 the2 yer2evts’2 errorF2exF2qov’t2gode2§2PHHIF@ASV@eA@lAF2
he2yer2evts2lso2erred2to2the2extent2tht2they2relied2on2tlIe2 rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pyp2PWD2 QID2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2 lw2nd2wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2qov’t2gode2 PH@AIFHSV@eA@PAF2 §2 woreoverD2 the2 proposed2 finding2 reflets2 2 fundmentl2 misunderstnding2 nd2 mispplition2of2exs2lw2nd2wediid2poliy2y2the2@Aer2evt2 sF2 en2 urte2 understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2is2 ritilly2 importnt2to2 the2outome2of2this2 disputeF2 he2fundmentl2llegtion2rought2y2 the2 snspetor2 qenerl2 is2 tht2 ehg2hs2 sumitted2 lims2 for2 e2 nd2 for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2ft2finder2does2not2understnd2the2 poliyF2hereforeD2there2is2 2rtionl2onnetion2etween2the2orret2rtiultion2of2 wediid2poliy2nd2the2 modified2finding2of2ftD2 whih2urtely2 reflets2 tht2 poliyF2eeF2eF2gFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2 FFQd2t2 RRHERIY2tte2 vF2 llGsidEouth2 versD2 snD2 PRT2FFQd2t2 UPVY2 vevy2vF2 exF2tte2f’2HfwedF2ixm2’rsD2 WTT2FFPd2t2VITF2 F2
SI2 hen2IEsrgEysq2rrived2t2ehg2in2xovemer2llD2 PHIPF2nd2sked2for2TQ2se2 ehg2ould2not2lote2eight2dentl2modelsD2 filesD2 prim2fie2evidene2exists2 tht2 rvh2sore2sheetsD2nd2two2preEtretment2x~rysF2 four2 SPF2 ehg2forwrded2the2 lE{vh2sore2sheets2 nd2supporting2doumenttion2to2 lGr2 when2ehg2filed2its2 requests2for2prior2uthoriztionF2 SQ2 rrgEysq2presented2prim2fie2evidene2tht2ehg2filed2to2retin2these2reords2 nd2models2for2the2required2five2yersF2 SR2 rrgEysq2 presented2prim2fie2 evidene2 tht2 is2 redileD2 relileD2 nd2 verifiedF2 nd2tht2 hs2indii2 of2reliility2 when2nlyzed2onsistently2with2 exs2 lw2 nd2 wediid2 poliyD2 tht2 ehg2illed2 or2 used2 lims2 to2 e2 sumitted2to2exs2wediid2for2servies2or2items2tht2re2not2reimursle2 y2the2exs2wediid2progrmF2 @he2 yesEs2 eFvts’2 proposed2 pop2 xoF2 SR2 sttedX2 rrgEysq2filed2 to2 present2 prim2fie2evilene2tht2ehg2illed2Hr2used2lims2to2 e2sumitted2sH2 exs
Q
001774 llGlediilfr2servies2or2items2tht2re2not2reimursle2y2the2 exs2wediid2 progrmFA2 eson2for2ghngeX2 roposed2pop2xoF2 SR2 ddresses2 2mixed2question2 of2ft2 nd2lwD2 nd2is2 2 soE2 lled2“legisltive2findingF42 hereforeD2the2ixeutive2gommissioner2hs2omplete2 disretion2to2modify2itF2 exF2 hep9t2of2viensing282egultion2vF2 2 hompsonD2 PHIQ2 v2QUWIRVTD2 t2 BT2 @“9Gn2 geny2enjoys2 omplete2 disretion2 in2 modifying2n2 Gvt9s2findings2nd2onlusions2when2those2findings2nd2onlusions2reflet22lk2 ol‘2 understnding2 or2 mispplition2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mith2vF2 woritemyorD2PHHQ2 v2 PIRHISWID2t2BPTEPU2@emphsis2ddedAAY2 exF2qov9t2gode2§2PHHIF SV@eA@AF2 he2ixeutive2gommissioner2modifies2roposed2pop2xoF2SR2euse2it2 mispplies2 exs2 lw2 nd2 wediid2poliyF2 lf2 the2 yer2evts2hd2 pplied2 the2 proper2 ww2 stndrd2 for2 etopi2 eruptionD2 onsistent2 with2 the2 2 provision2 requiring2 providers2to2e2“onservtive”2in2soringD2to2the2fts2of2this2seD2then2the2yer2 ev2s2 would2hve2onluded2tht2rrgEysq2presented2prim2fie2evidene2tht2 in2t2lest2SV2of2the2TQ2ses2in2the2smple2ehg2sumitted2e2requests2for2ptients2 who2were2not2qulified2for2full2orthodontiF2 he2yess2evts2lso2orrd2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pop2PWD2 QID2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2nd2wediid2poliyD2 nd2 thereforeF2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHlFHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 reflets2 2 fundmentl2 misunderstnding2 nd2 mispplition2of2exs2lw2nd2wediid2poliy2y2the2yer2evssF2en2urte2 understnding2of2the2 sope2nd2limittions2of2exs2wediid2poliy2is2 ritilly2 importnt2to2 the2 outome2of2this2 disputeF2 he2fundmentl2llegtion2rought2y2 the2 lnspetor2 qenerl2 is2 tht2 ehg2 hs2 sumitted2 lims2 for2 e2 nd2 for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2hese2 llegtions2nnot2e2properly2evluted2if2the2deision2mker2does2not2understnd2 the2 poliyF2 hereforeD2 there2 is2 2 rtionl2 onnetion2 etween2 the2 orret2 rtiultion2of2wediid2poliy2nd2the2modified2finding2of2ftD2 whih2urtely2 reflets2tht2poliyF2eeD2eFgFD2reritge2on2the2ri2 qriel2romeowners2essoF2 vF2 giF2QWQ2FFQd2t2RRHERIY2tte2vF2 widEouth2veG‘sD2snD2PRT2FFQd2t2UPVY2 v€{2vF2 exF2tte2felF2 HfFwedF2ixm rsD2 WTT2FFPd2t2VITF2 ‘2
ehg2ommitted2progrm2violtions2 when2 sumitted2 prior2uthoriztion2 it2 requests2nd2rvh2forms2for2hVHVH2omprehensive2orthodonti2tretmentD2of2 tients2ISD2STD2nd2TH2when2these2ptients2did2not2qulify2por2omprehensive2 orthodontisF
QP
001775 @he2 yer2esFFts’2 proposed2 pop2xoF2 SS2 sttedX2 tient2 sSD2 STD2 nd2THD2 were2 eligile2for2intereptive2tretment2under2exs2wediidFA2
eson2for2ghng2 eX2
roposed2pp2xoF2 SS2 ddresses2 2mixed2question2 of2ft2 nd2lwD2 nd2is2 2 soE2 lled2“legisltive2findingF”2 hereforeD2the2ixeutive2gommissioner2hs2omplete2 disretion2to2modify2itF2 exF2 hep’t2of2viensing282egultion2vF2 hompsonD2 PHIQ2 v2QUWIRVTD2 t2 BT2 @“en2geny2enjoys2 omplete2 9isErerion2 in2 modifying2n2 Gvt9s2lindings2nd2onlusions2when2those2findings2nd2onlusions2reflet22lk2 understnding2 or2 mispplition2 ol’2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 oi‘2
@quoting2mith2vF2 wontemyorD2PHHQ2 v2PIRHISWID2t2BPTEPU2@emphsis2ddedAAY2 exF2qov4t2gode2§2PHHIFHSV@eA@lAF2 he2ixeutive2gommissioner2modifies2roposed2pop2xoF2SS2euse2it2mispplies2 exs2lw2nd2wediid2poliyF2 o2the2extent2the2yer2evts2use2“intereptive”2 tretment2to2men2something2less2 thn2omprehensive2oithodontis2hVHVH2@nd2 therefore2 outside2 the2 requirement2tht2 ptients2 e2 IP2 or2 older2or2hve2no2y2 teethAD2 the2 yer2evts2misstte2 the2 evideneF2 ehg2illed2 the2 ode2hVHVH2for2 these2 ptientsF2 mening2they2 flsely2 represented2to2 the2 stte2 tht2 these2 ptients2 were2 IP2 or2older2or2hd2lost2 ll2 y2teethF2 o2the2 extent2the2 @Aer2evts2use2 “intereptive”2to2 inlude2ode2hVHVHD2see2ix2EIS2t2 §2 lWFlVFUD2they2re2gin2in2 errorX2 hVHVH2is2expliitly2not2pplile2to2ptients2like2these2who2hve2y2teeth2 nd2re2under2IP2yers2oldF2 hese2ptients2 my2well2 hve2een2eligile2 for2 intereptive2 tretment2—2tht2 isD2 something2less2thn2omprehensive2orthodontis2—2ut2the2evidene2in2 this2 se2is2 lerX2 ehg2illed2wediid2for2—2nd2represented2to2the2 tte2tht2these2ptients2 qulified2for2—2hVHVHD2or2omprehensive2orthodontisF2 por2exmpleD2with2regrd2 to2 tient2 ISD2 the2 h2 sttes2 tht2 ehg2requested2 “prior2 uthoriztion2 for2 intereptive2 tretmentF42 ph2 t2 QQF2 ehg2 requested2 hVHVHF2 omprehensive2 orthodontisF2for2this2ptientD2even2though2the2ptient2ws2W2yers2old2nd2hd2y2 teethF2 ~lS2 t2 lS~HHIW2@ehg2rior2euthoriztion2equest2porm2for2tient2 lS2 requesting2 “AVHVH”FA2 his2 is2 2 progrm2 violtionF2 I2 exF2 edminF2 gode §2 QUIF2lTlU@lA@uA2nd2@SA@qAF2 ith2regrd2to2tient2STD2ehg2requested2hVHVH2omprehensive2orthodontis2for2 this2ptientF2even2though2the2ptient2ws2W2yers2old2nd2hd2y2teethF2ixF2EST2 t2 STEHHIS2 @ehg2rior2euthoriztion2equest2 porm2for2 tient2 ST2 requesting2 “hVHVH”2for2 2hrge2of26UUSFHHFA2 his2is2 2progrm2violtionF2 I2 exF2edminF2 gode2§2Q’GIFlTlU@lA@uA2nd2@SA@qAF2 ehg2 pinllyD2 for2 tient2THF2 requested2hVHVH2omprehensive2orthodontisD2even2 though2this2 ptient2ws2under2lP2nd2hd2y2teethF2 ixF2ETH2t2 THEHHHR@ehg2 rior2euthoriztion2equest2porm2for2 tient2TH2requesting2“hVHVH”2for22hrge
001776 ol’6UUSFH@AFAF2 his2is2 2progrm2violtionF2 l2 exF2edminF2gode2 QUlFlTlU@IA@uA2 §2 nd2@SA@qAF2 he2pt2 tht2 ehg2 illed2for2omprehensive2orthodontis2when2their2ptients2did2 not2qulify2for2tht2tretment2is22progrm2violtionD2nd2wrrnts22pyment2holdF2 he2yer2esFFts2lso2erred2to2 the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 pop2PWD2 QID2 nd2QQD2 for2 their2 understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 oi’2 exs2 lw2nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov”X2gode2§2PH@AIFHSV@eA@PAF2
en2urte2understnding2of2the2sope2nd2limittions2of2exs2wediid2poliy2 is2 ritilly2importnt2 to2 the2 outome2 of2 ny2 disputeF2 ellegtions2 nnot2 e2 properly2evluted2if2the2 deision2mker2does2not2properly2interpret2 nd2pply 2 poliyF2hereforeD2there2is2 2rtionl2onnetion2etween2the2orret2rtiultion2of2 wediid2poliy2 nd2 the2 ltered2 finding2of2ftD2 whih2urtely2 reflets2 tht2 poliyF2eeD2eFgFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2 FFQd2RIUD2 RRHERI2 @exF2 eppF—eustin2PHIPD2pet2 deniedAY2 lte2 vF2 wi’Eouth2 versD2snFD2 PRT2FFQd2UIID2UPV2@exF2eppF~eustin2PHHUD2petF2 deniedAY2vevy2vF2 wedF2ixm2’rsD2 WTT2FFPd2VIQD2VIT2@exF2eppF—eustin2IWWVF2no2 exF2tte2felF2 of2 petFAF2
rogrm2violtions2rnge2from2“very2innouous”2to24very2importntF”2 ehg’s2 reord2 keeping2 violtionsD2 together2 with2 the2 prim2fie2 evidene2 presented2 y2 rrgEysq2of2ehg’s2frud2 nd2 willful2 misrepresenttionsD2 when2 nlyzed2 onsistently2 with2 exs2 lw2 nd2 wediid2 poliyD2 justify2 mintining2the2pyment2holdF2 @he2yer2evts’2 proposed2pol‘2 xoF2 U2sttedX2 ehg s2violtion2 is2 2tehnil2 ‘2
violtion2 nd2sed2upon2 this2 reord2does2 not2 rise2 to2 2 level2 of2sustntive2 onernFA2 eson2for2ghngeX2 roposed2polc2 xoF2SU2ddresses2 2mixed2question2of2ft2 nd2lwD2 nd2is2 2soE2 lled2“legisltive2findingF42 hereforeD2the2ixeutive2gommissioner2hs2omplete2 disretion2to2modify2itF2 exF2 hep’t2loG4viensing282egultion2F2 hompsonD2 HIQ2 v2QUWIRVTD2 t2 BT2 @“en2geny2enjoys2 omplete2 disretion2 in2 modifying2n2 evt9s2findings2nd2onlusions2when2those2findings2nd2onlusions2reflet22lk2 of2 understnding2 or2 mispplition2 of2 the2 existing2 lwsD2 rulesD2 or2 poliiesF”2 @quoting2mith2vF2 wontemyorD2PHHQ2 v2 PIRHISWID2t2BPTEPU2@emphsis2dddAAY2 exF2qov’t2gode2§2P@AHIFHSV@A@lAF2 roposed2pop2xoF2SU2is2 erroneous2euse2it2 inispplies2exs2lw2nd2wediid2 poliyD2 inluding2to2 the2extent2this2 finding2rests2on2the2 flse2premise2tht2ehg’s
QR
001777 reord2keeping2violtions2re2the2only2tionle2violtions2found2y2the2snspetor2 qenerlF2 he2yer2evts2pper2to2 reson2tht2 Ghg’s2progrm2violtionsD2 y2 themselvesF2 do2 not2justify2 ontinution2 of2thepyment2holdF2 he2underlying2 premiseD2 in2 turnD2 is2 sed2the2 yesEs2 evts2mispplition2 of2exs2wediid2 poliy2regrding2 etopi2 eruptionF2 his2 finding2is2 lso2 erroneous2 euse2 it2 is2 within2the2 sound2disretion2 of2the2 ixeutive2 gommissionerD2nd2not2the2 yess2 evtsD2to2determine2whether2or2not2ehg92 s2reord2keeping2violtions2re2use2for2 onemF2 he2snspetor2 qenerl2sed2 his2 pyment2 holdD2 in2 pnD2 on2 ehg’s2filure2 to2 provide2reords2pursunt2to2 the2 snspetor2qenerl’s2requestF2 sn2some2sesD2ehg2 hd2these2reordsD2nd2entered2them2into2evidene2in2this2ese2over22yer2qfler2the2 snspetor2 qenerl2 requested2 themF2 ehg’s2 filure2 to2 provide2 these2 reords2 immeditely2 is2 2 progrm2 violtion2 nd2my2result2 in2 2 pyment2holdF2 s2 exF2 edminF2gode2§2 QUIFlTlU@PA@GAY2 EsR2t2 sEV2 @“pilure2 to2 supply2the2requested2 douments2 nd2 other2 itemsF2 within2 the2 time2 frme2 speifiedD2 my2result2 in 2 pyment2hold2 or2exlusion2from2wediidf‘AF2 F2 F2 F2
roposed2pop2xoF2 SU2is2 erroneous2 in2 hrterizing2these2progrm2violtions2 s2 4tehnil2violtions”2tht2re2not2“of2sustntive2onemD”2prtiulrly2in2light2 of2the2 ft2tht2 the2 snspetor2qenerl2is2 oligted2to2 investigte2wediid2frudD2 wsteD2 nd2 useD2 ndD2 in2 the2 ourse2 of2 investigtingD2 is2 entitled2 to2 request2 douments2 of2providersF2 ixF2 EsR2 @PHHV2 wwA2§2 IFPFQF2 siurthermoreD2 the2 snspetor2qenerl2is2 entitled2to2 se2pyment2hold2determintions2on2the2reords2 tht2wediid2providers2provide2in2response2to22proper2request2on2the2prt2of2the2 snspetor2 qenerlF2 wediid2 providers42 filure2 to2 provide2 douments2 to2 the2 snspetor2 qenerl2 pursunt2 to2 2 written2 request2 for2 them2 is2 2 “sustntive2 onernF”2 prtiulrly2 in2 sesD2 like2this2 oneD2where2the2 provider2lter2ttks2the2 vlidity2 of2the2 pyment2hold2 sed2on2the2 existene2 of2douments2 it2 filed2 to2 provide2 to2 the2 snspetor2 qenerlF2 he2 existene2 nd2 provision2 of2douments2 neessry2to2 fully2 doument2nd2evlute2 the2 neessity2nd2delivery2of2medil2 servies2 is2 prmount2to2the2integrity2of2the2wediid2systemF2ee2iere2vF2 exF2 ing2gomm2UID2 PIP2 FFQd2URSD2 USR2 @exF2 eppF—eustin2PHHTD2 petF2 deniedA2 @geny2detemiines2pproprite2 penlty2to2 further2genyG’s2 gols2 of2ompline2 with2 stte2 lwA2 @iting2 piremen9s2 82 Hliemen9s2 givil2 ervF2 gHmm9n2 vF2 frlnkmeyerD2TTP2FFPd2WSQF2WST2@exF2IFWVRAAY2 ee2lso2 exF2 tte2f’2 of2hentl2 F2
ixm rs2 vF2 frownD2PVI2 FFQd2TWPD2TWU2@exF2 GppF—gorpus2ghristi2 PHHWD2petF2 92
deniedA2@genyD2not2evsD2determines2pproprite2sntionAF2 he2yer2evts2lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 p2op2PWF2 QIF2 nd2QQD2 for2their2understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n
QS
001778 inorret2 interprettion2 nd2pplition2 of2exs2 lw2 nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
woreoverD2 the2 proposed2 finding2 rellets2 2 fundmentl2 misunderstnding2 nd2 mispplition2ol’2exs2lw2nd2wediid2poliy2y2the2yer2evt2 sF2 en2urte2
understnding2of2the2sope2nd2limittions2 of2exs2wediid2poliy2is2 ritilly2 importnt2to2the2outome2of2this2 disputeF2 he2fundmentl2llegtion2rought2y2 the2 snspetor2 qenerl2 is2 tht2 ehg2hs2 sumitted2 lims2 for2 e2 nd2 for2 reimursement2tht2re2not2uthorized2under2wediid2poliy2or2exs2lwF2 hese2 llegtions2nnot2e2properly2evluted2if2the2ft2finder2does2not2understnd2the2 poliyF2hereforeD2there2is2 2rtionl2onnetion2etween2the2orret2rtiultion2of2 wediid2poliy2 nd2the2modified2finding2of2ftD2 whih2urtely2reflets2tht2 poliyF2eeD2 eF2gFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2 FFQd2t2 RRHERIY2tte2 vF2 wi’Eouth2versD2 snD2 PRT2FFQd2t2 UPVY2vevy2vF2 exF2tte2fdF2HfwedF2ixm2’rsD2 WTT2FFPd2t2VITF2
gyxgv syx2yp2ve2 rrgEylq2hs2jurisdition2over2this2 seF2 exF2qov9t2gode2hF2 SQY2exF2 rumF2 esF2gode2hF2QPF2 yer2hs2jurisdition2over2the2hering2proess2nd2the2preprtion2nd2issune2 of22proposl2for2deisionD2with2findings2of2ft2nd2onlusions2of2lwF2exF2qov9t2 gode2hF2PHHQF2 xotie2of2the2hering2ws2properly2providedF2exF2qov9t2gode2hF2PHHIF2 he2snspetor2qenerl’s2urden2to2 mintin2the2pyment2hold2under2setion2 SQlFlHP@gA@PA2of2the2 qovernment2gode2or2setion2 QPFHPWl@A2 of2the2 rumn2 esoures2godeD2is2 to2show2y2relile2or2prim2fie2evidene2tht2ehg2hs2 ommitted2frud2or2mde2willful2misrepresenttionsF2 @he2 yer2evts’2 proposed2gov2xoF2 R2 sttedX2 rrgEysq2hd2the2 urden2of2 proofA2 eson2for2ghngeX2 he2ixeutive2gommissioner2modifies2roposed2gov2xoF2RF2 roposed2gov2xoF R2 is2 erroneous2 euse2 it2 is2 2 missttement2 of2the2 lwF2 ee2 exF2 qov‘t2 gode §2
PH@AlF@ASV@eA@IAF2 he2inspetor2 qenerl2 is2 required2y2lw2to2 impose2 2 pyment2 hold24on2reeipt2of2relile2evidene2tht2the2irumstnes2giving2rise2to2the2hold2 on2pyment2involve2 frud2or2willful2 misrepresenttion2under2the2 stte2 wediid2 progrm2 in2 ordne2 with2 RP2 gFpFF2 etion2 RSSFPQF“2 exF2 qov’t2 gode §2 SQlFlHP@gA@PAF2 edditionllyF2 4the2 deprtment2shll2 disontinue2the2hold2unless2 the2deprtment2mkes22primGizie2showing2t2the2hering2tht2the2evidene2relied2 on2y2the2deprtment2in2imposing2the2hold2is2 relevntD2redile2nd2mteril2to2the2 issue2of2frud2or2willful2 misrepresenttionF“2 exF2 rumF2esF2gode2§2 QPFHPWl@A
QT
001779 @emphsis2 ddedAF2 feuse2 the2 yer2 GEvts’2 proposed2 onlusion2 of2 lw2 misstted2 the2 pplile2 lwD2 the2 ixeutive2 gommissioner2 hs2 disretion2 to2 modify2 itF2 hompsonD2 PHIQ2 v2 QUWIRVTD2 t2 BTY2 exF2 qHv’t2 gode §2 PHHlFHSV@eA@lAF2 he2HGEFr2evs2 s2 lso2erred2to2the2extent2tht2they2relied2on2the2rrlingen2pmily2 hentl2deisionD2prtiulrlyD2pop2PWD2 QID2 nd2QQD2 for2 their2 understnding2of2the2 sope2nd2limittions2 of2exs2wediid2poliyF2 he2ixeutive2 gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2exs2lw2 nd2iGlediid2 poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2§2PHHI2FHSV@eA@PAF2
woreoverD2the2 proposed2onlusion2reflets2 2fundmentl2misunderstnding2nd2 mispplition2of2exs2lw2y2the2 yer2ev2sF2 hereforeD2there2 is2 2rtionl2 onnetion2etween2exs2lw2nd2wediid2poliy2nd2the2modified2onlusion2 of2lwF2eeD2eF2gFD2 reritge2on2the2n2qriel2romeowners2essoF2 vF2 giD2QWQ2 FFQd2t2 RRHERIY2tte2vF2 widEouth2versD2 snFD2 PRT2FFQd2t2 UPVY2vevy2vF2 exF2tte2f’2 ofwedF2ixm2’rsD2 WTT2FFPd2t2VITF2 F2
S knowingly2mke2or2use2to2e2mde22flse2sttement2or2 lt2 is2 n2unlwful2t2to2
misrepresenttion2 of22 mteril2 ft2 to2 permit2 2 person2to2 reeive2 2 enefit2 or2 pyment2under2the2wediid2progrm2tht2is2 not2uthorized2or2tht2is2greter2thn2 the2 enefit2 or2 pyment2 tht2 is2 uthorizedF2 exF2 rumF2 esF2 gode2 §2 QTFHHP@lA2 @PHHQAF2 T he2term2“knowingly”2mens2tht2 the2 person2hs2knowledge2of2the2 informtionD2 ts2with2onsious2indifferene2to2the2truth2or2flsity2of2the2informtionD2or2ts2in2 rekless2disregrd2of2the2truth2or2flsity2of2the2informtionF2roof2of2the2person‘ s2 speifi2intent2to2ommit2n2unlwful2t2under2§2 QTFHHP2is2 not2required2to2 show2 tht22person2ted2“knowinglyF”2exF2lsElumF2 esF2gode2§2QTFHHII2@PHHQAF2
U2 “prud”2is2n2intentionl2deeption2or2misrepresenttion2mde2y22person2with2the2 knowledge2tht2 the2 deeption2ould2result2 in2 some2unuthorized2enefit2to2 tht2 person2 or2 some2 other2 personD2 inluding2 ny2 t2 tht2 onstitutes2 frud2 under2 pplile2federl2or2stte2lwF2exF2qov4t2gode2§2SQIFIHI2I@IA2@PHI2IAF2
VF2 l9Il~lgEysq2 must2 impose2 2 hold2 on2 pyment2 of2 lims2 for2 reimursement2 sumitted2 y2 2 provider2 on2reeipt2 of2relile2 evidene2 tht2 the2 irumstnes2 giving2rise2to2the2hold2on2pyment2involve2frud2or2willful2misrepresenttion2under2 the2stte2wediid2progrmF2exs2qov’t2gode2§2SQ2lFlHP@gA@PA2@PHI2IAF2
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QU
001780 suspension2 my2 e2 ontinued2 until2 suh2 time2 s2 the2 investigtion2 nd2 ssoited2enforement2proeedings2re2ompletedF2 ny2 RP2gFpFF2§2RSSFPQ2@PHI2lAF2 e2 “gredile2 llegtion2 of2frud”2 my2e2 “n2 llegtionD2 whih2 hs2 een2 verified2y2the2tteD2 from2ny2soure”2inludingD2 ut2not2limited2toD2 ‘frud2 hotline2 omplintsD2 lims2 dt2 miningD2 nd2 ptterns2 identified2 through2 provider2 uditsD2 nd2 lw2 enforement2 investigtionsF2 ellegtions2 re2 onsidered2 redile2 when2 they2 hve2 indii2 of2 reliility2 nd2 the2 tte2 wediid2geny2hs2 reviewed2 ll2 llegtionsD2 ftsD2 nd2 evidene2refully2 nd2ts2judiiously2on22se—yEse2sisF”2RP2gFpFF2 §2RSSFPF2 @he2yer2evts92proposed2gov2x2 oF2 lH2sttedX2 4gredile2llegtion2 42 “2 n2llegtionD2whih2hs2een2verified2y2the2tteD2fi9onz2 offrud2 is 42 ny2soureD2 inludingD2 for2exmpleD2fi9zGd2hotline2 omplintsD2 lims2dt2 miningD2 nd2provider2uditsD2 ellegtions2re2onsidered2redile2when2they2hve2 indii2of2reliility2nd2the2 tte2wediid2geny2hs2reviewed2ll2 llegtionsD2ftsD2 nd2evidene2rejillly2 nd2ts2judiiouslv2on22seEyEse2sisF2RP2@FspFF2 RSSFP2 §2 @PHIIAF2”FA2 eson2for2ghngeX2 he2ixeutive2gommissioner2modifies2roposed2gov2 xoF2 IHF2 roposed2gov2xoF2 IH2omits2words2nd2phrses2from2the2 sttuteD2 ll2 essentil2 to2 the2mening2of2the2 sttuteX2 ‘“ptterns2 identified2 through‘2 provider2 udits”Y2 the2 yer2evts2 lso2 deleted2the2phrse2“nd2lw2enforement2investigtions”2 “is”2for2“my2e”2 nd2sustituted2the2word2 nd2“for2exmple42for2“ut2not2limited2toF”2 feuse2 roposed2 gov2 xoF2 lH2 inorretly2 sttes2 the2 lwD2 the2 ixeutive2 gommissioner2hs2omplete2disretion2to2modify2gov2xoF2 IH2to2orretly2stte2the2 lwD2dd2the2essentil2phrses2nd2ords2of2“ptterns2 identified2through42nd2“nd2 lw2enforement2investigtions”2 nd2sustitute2 the2 ords2“n2e”2 for2“is”2 nd2 “ut2not2limited2to”2for2“for2exmpleF”2 ee2hompsonD2PHIQ2v2QUWIRVTD2t2 BTY2 exF2qov’t2 gode2§2PHHIFHSV@eA@lAF2 he2yer2evts2lso2erred2to2the2extent2tht2they2relied2 on2the2rrlingen2pmily2 hentl2deisionD2 prtiulrlyD2 polc‘2 PWD2 QID2 nd2 QQD2 for2their2 understnding2of2the2 sope2nd2limittions2 of2exs2wediid2 poliyF2 he2ixeutive2gommissioner2 dispproves2of2these2findingsD2nd2expressly2onludes2 tht2they2were2sed2on2n2 inorret2 interprettion2 nd2pplition2 of2 exs2lw2nd2wediid2poliyD2 nd2 thereforeD2nnot2e2relied2onF2 exF2qov’t2gode2 §2PHHlFHSV@eA@PAF2 woreoverD2 euse2 the2 proposed2 onlusion2 reflets2 2 fundmentl2 misunderstnding2nd2mispplition2of2lw2 the2yer2 y2 evtsD2there2is22rtionl2 onnetion2etween2exs2lw2nd2wediid2 poliy2nd2the2modified2onlusion2 of2lwF2eeD2eFgFD2reritge2on2the2n2qriel2 romeowners2essoF2 vF2 giD2QWQ2 FFQd2t2 RRHERIY2tte2 vF2 widEouth2versD2 lnFF2 PRT2 FFQd2t2 UPVY2 vevy2vF2 exF2tte2fdF2 ofzlGledF2 ixm rsD2WTT2 FFPd2t2VITF 92
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001781 ‘vY»9X—XFE E F2
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001785 Append¡x B lexas I Medicaid.gov Page 1 ofl Learn about yg!Lhgq!!h!3Ig_9pl!!9!9 lhtto://www.healthca¡e.qovl
Medicaid,q* Keeping Ameríca Healthy (/index.html)
Return to previous paqe
lome (/index.html) ¡ ) BY State
Texas (/medica id-ch ip-oroqram-information/bv-state/bv-state. html) State of Texas Website (http:i/www. h hsc. state. tx. u s/)
Med icaid-Marketplace Overview The Federally-facilitated Marketplace (FFM) is offering health coverage in Texas in 2015. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant's account to the state agency for a final eligibility determination. Texas has not expanded Medicaid coverage to low-income adults.
Medicaid and CHIP Eligibility Levels To view the income-and-medicaid-chip.pdfl -based eligibility levels, expressed as a percentage of the federal poverty level (FPL) and by monthly dollar amount and family size for Medicaid and cHlP, visit the for more information.
State Medicaid Expansion Ghildren - Medicaid Separate CHIP Pregnant Women Parents3 Other Adults Ages 0-11 Ages 1-52 Ages 6-182 Medicaid CHIP Texas N 198% 144% 133% 201% 198o/o N/A 15% 0%
1. These el¡g¡b¡l¡ty standards include CHIP-funded Medicaid expans¡ons.
2 Children in separate CH\P programs are typically charged premiums Th¡s table does not include notations of states that have elected to provide CHIP coverage from conception lo bit1h,
3 /n slafes that use dollar amounts rather than percentages of the federal poverty level (FPL) for 2013 to detemine eligibility for parents, we convefted those amounts to a percent of lhe FPL and selected the highest percentage to reflecl eligib¡lity level for the group ln additíon, ¡n states that are adopting the Medicaid expansion, we have indicaled the upper ¡ncome timit for parents to also be 133% of the FPL, s¡nce parents can be eligible for coverage under the new adult group. The actuat dottar standards that states w,// use to determine eligibility are quoted in the monthly ¡ncome tables
Monthly Medicaid and CHIP Enrollment Data Each month, CMS releases state-reported data on State Medicaid and CHIP program Enrollment. The enrollment data for each month is a point.in- time count of total Medicaid and CHIP enrollment on the last day of the month, and is not solely a count of those newly enrolled during the reporting period. Below,thisdataiscomparedtoaverageenrollmentfromJuly-September20l3,theperiodbeforetheinitial openenrollmentperiodofthe Health lnsurance Marketplaces. Additional information and enrollment data is available on the Medicaid and CHIP Application, Eliqibility
State State Medica¡d & CHIP Enrollment National Total Medica¡d & CHIP Comparison of February Total Medicaid & CHIP Gomparison of February 2015 Enrollment (February 2015 data to July-September Enrollment, all States data to July-September 2013 2015) (Preliminary) 20'l 3 Average Enrollment (February 2015) Average Enrollment Net Change % Change (Preliminary) Net Change % Change Texas 4,655,609 214,004 4 82% 70,5'15,716 11 ,718,178 20 28%
Medicaid and CHIP Applications The Affordable Care Act established a streamlined enrollment process through which individuals can gain access to affordable insurance coverage for which they are eligible. The law directed the Secretary of Health and Human Services (HHS) to develop a model application that will be used to . States have the option to adopt the Secretary of HHS's model application form for affordable insurance programs or to adopt an alternative application that meets federal requirements
rttp://www.medicaid.gov/Medicaid-CHlP-Program-lnformatiorVBy-State/texas.html 51281201: lexas I Medicaid.gov Page2 of ':
ln response to , many states have adopted one or more "targeted enrollment strategies" designed to facilitate enrollment and retain coverage for eligible individuals in Medicaid/CHlP. The states that have adopted one or more targeted enrollment strategies are listed on the Targeted Enrollment Strateqies (/medicaid-chip-proqram- page.
Medicaid and CHIP State Plan Amendments The state Medicaid and CHIP plans spell out how each state has chosen to design its program within the broad requirements forfederal funding. As always, states amend their Medicaid and CHIP state plans in order to inform CMS of programmatic and financing changes and to secure legal authority for those changes. The Affordable Care Act included many new opportunities for states to augment and improve their Medicaid and CHIP programs. As a result there has been a great deal of state plan amendment activity over the past several years in the areas of eligibility, benefits design and financing, as well as new approaches to providing health homes, long{erm services and supports, and enrollment strategies like hospital presumptive eligibility. See below for a state-specific list of approved Medicaid and CHIP SPAs.
Amendments. htm l?filterBv=Texas)
Demonstrations and Wa¡vers Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(b) managed care waivers, and section 1 915(c) home and community-based services waivers. More information about waivers is available on the Waivers (/medicaid-chip- oroqram-information/bv{opics/wa ivers/waivers. html) page.
filterBv=Texas)
Medicaid Delivery System States have choices in their approach to delivery system design under the Medicaid and CHIP programs. States are increasingly moving to the use of and olhqjnleffated-gele in serving their Medicaid beneficiaries. On average, more than 70 percent of the Medicaid population is enrolled in some form of managed care.
GHIP Program lnformation was established in 1997 to provide new coverage opportunities for children in families with incomes too high to qualify for Medicaid, but who cannot afford private coverage. Like Medicaid, CHIP is administered by the states, but is jointly funded by the federal government and states. States had the opportunity to desiqn their CHIP proqrams (/chip/downloads/chip-map.pdfl as an expansion of Medicaid, as a stand-alone program orthrough a combined approach.
Medicaid/CHIP Participation Rates The participation rate is the percentage of eligible children enrolled in Medicaid and CHIP in the state. Data from 2013 show 88.3 percent of the eligible children in the Unifed States are enrolled in Medicaid and CHIP programs. More information about the participation rate among children in Texas is available on
State Participation Texas 83.7%
Medicaid/G HIP Eli gi bi lity Verification Plans Medicaid and CHIP agencies now rely primarily on information available through data sources (e.9., the Social Security'Administration, the Departments of Homeland Security and Labor) rather than paper documentation from families for purposes of verifying eligibility for Medicaid and CHIP.
Texas's Medicaid and CHIP Verification
MAGI Gonversion Plans CMS provided states w¡th a template for completing their "MAGl Conversion Plans" that are designed to reflect the MAG|-based eligibility standards that are used to determine Medicaid and CHIP eligibility. The MAG|-conversion process involved a translation oÍ pre-2014 net income eligibility standards into MAGI-based eligibility standards. Moving to MAGI replaced income disregards with simpler, more universal income eligibility rules that are generally aligned with the rules that are used to determine eligibility for the premium tax credits in the Marketplace. To complete the transformation to MAGI, states needed to "convert" their nelincome based eligibility standards to MAG|-based standards. . Texas's MAGI Conversion Plan is currently in progress
marketplace/downloads/tx-converted{hresholds-26ap1201 3. pdf)
rttp://www.medicaid.gov/Medicaid-CHIP-Program-lnformatiorVBy-State/texas.html 5128120t: Append¡x G Texas Medicaid and CHIP n Perspective Tenth Edition
Texas Health and Human Services Commission February 2015 Ghapter 1: Texas Med¡ca¡d I n Perspective What is Medicaid? What is Medicaid managed care? How is lexas Medicaid changing?
What ls Medicai d? Medicaid is a jointly funded state-federal health care program, established in Texas in 1967 and administered by the Health and Human Services Commission (HHSC). ln order to participate in Medicaid, federal law requires states to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). Each state chooses its own eligibility criteria within federal minimum standards. States can apply to the Centers for Medicare & Medicaid Services (CMS) for a waiver of federal law to expand health coverage beyond these groups. Medicaid is an entitlement program, which means the federal government does not, and a state cannot, limit the number of eligible people who can enroll, and Medicaid must pay for any services covered under the program. ln July 2013, about one in seven Texans (3.7 million of the 26.4 million) relied on Medicaid for health coverage or long-term services and supports.
Medicaid pays for acute health care (physician, inpatient, outpatient, pharmacy, lab, and x-ray services), and long-term services and supports (home and community-based services, nursing facility services, and services provided in lntermediate Care Facilities for lndividuals with an lntellectual Disability or Related Conditions (lCFs/llD))for people age 65 and older and those with disabilities. ln state fiscal year (SFY)2013, total expenditures (i.e. state and federal) for Medicaid were estimated to represent26.2 percent (about $25.6 billion) of Texas' budget'. The federal share of the jointly financed program is determined annually based on the average state þer capita income compared to the U.S. average. The federal share is known as the federal medical
i All funds, excluding disproportionate share hospital (DSH), uncompensated care (UC), and Delivery System lmprovement Program (DSRIP). Sources: Texas Medicaid History Report, August 2014, and Fiscal Size-Up(s)..
1-1 Append¡x D TÐI{S MEDICATD PnovIDER PROCEDURE S MNNUAL
Volumes 1&2
This nra¡rual is available for download at www.tnrhp.conr, and ìs also available on CD. There are n'ìany benefits to using the ele ctronic manual, includirrg easy navìgation r¡rith booknrarks and hyperlinked cross-references, the abílìty to quickly search for speclfic terms or codes, and form printing on demand.
The Texas Medicaid & Healthcare Partnership (TM H P) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL.2
4.2.23 Hospitalization and ASC/HASC Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may be benefits of THSteps based on the medical or behavioral justification provided, or if one of the following conditions exist: . The procedures cannot be performed in the dental office. . The client is severely disabled.
To satis$r the preadmission history and physical examination requirements of the hospital, ASC, or HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the child's primary care provider. Physicians who are not enrolled as THSteps medical providers must submit claims for the examination of a client before the procedure with the appropriate evaluation and management procedure code from the following table:
Procedure Code Place of Service (POS)
99202 POS I (office) 99222 POS 3 (inpatient hospital) 99282 POS 5 (outpatient hospital)
Refer to: Subsection 5.3.l.6, "Exception-to-Periodicity Checkups" in this handbook.
Note: The dental provider must submit claims to TMHP using the ADA Dental Claim Form to be considered for reimbursement through THSteps Dental Services.
The dental provider is responsible for obtaining prior authorization for the services performed under general anesthesia. Hospitals, ASC's, and anesthesiologists must obtain the prior authorization number from the dental provider. Contact the individual HMO for precertification requirements related to the hospital procedure. If services are precertified, the provider receives a precertification number effective for 90 days.
In those areas of the state with Medicaid managed care, the provider should contact the managed care plan for specific requirements or limitations. It is the dental provider's responsibility to obtain precerti- fication from the client's HMO or managed care plan for facility and general anesthesia services if precertification is required. To be reimbursed by the HMO, the provider must use the HMO's contracted facility and anesthesia provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthe- siologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is the responsibility of the client's primary care provider. The primary care provider must be notified by the dentist or the HMO of the planned services.
Dentists providing sedation or anesthesia services must have the appropriate current permit from the TSBDE for the level of sedation or anesthesia provided.
The dental provider must be in compliance with the guidelines detailed in General Information.
Note: Post-treatment authorizøtion will not be approved for codes that require mandatory prior authorization.
4.2.24 Orthodontic Services (THSteps) Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid. Orthodontic services are limited to the treatment of children who are l2 years of age and older with severe handi- capping malocclusion, children who are birth through 20 years of age with cleft palate, or other special medically necessary circumstances as outlined in Benefits and Limitations, which follows.
cH-r 82 CPT ONLY, COPYRIGHT 20IOAMERICAN MEDICAL ASSOCIATION ALL RICHl'S RESERVED CHILDRENS SERV]CES HANDBOOK
4.2,24.1 Benefits and Limitations Orthodontic services include the following: . Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index. A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered). Refer to: Subsection 4.2.26,"Handicapping Labio-lingual Deviation (HLD) Index" in this handbook.
Exception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefitfrom early treatment. Cleft paløte cases do not have to meet the HLD 26-point scoring requirement. Howeyer, it is necessary to submít ø sufficient narrøtive or outline of the proposed treatment plan when requesting authorization for orthodontic services on cleft pølate cases. . Crossbite therapy. . Head injury involving severe traumatic deviation.
The following limitations apply for orthodontic serylces: . Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps. . Orthognathic surgery, to include extractions, required or provided in conjunction with the appli- cation of braces must be completed while the client is Medicaid-eligible in order for reimbursement to be considered. . Except for procedure code D8660, all orthodontic procedures require prior authorization for consideration of reimbursement. . The THSteps client must be Medicaid THSteps-eligible when authorization is requested and the orthodontic treatment plan is initiated. It is the provider's responsibility to verifr that the client has a current Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Forms H1027 andHl027-A-C); that the date of birth on the form indicates the client is 20 years of age or younger; and that no limitations are indicated.
. Prior authorization is issued to the requesting provider only and is not transferable to another provider. Ifthe client changes providers or ifthe provider ceases to be a Medicaid provider for any reason, a new prior authorization must be requested by the new provider.
Refer to: Subsection 4.2.24.4, "Transfer of Orthodontic Services" in this handbook.
The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services under THSteps dental services: . Procedure code D8660 is allowed when: . The client is referred to a dental provider to determine whether orthodontic services are indicated and to determine the appropriate time to initiate such services. . The client is referred to a dental provider and elects to receive services from another orthodontic provider for justifiable reasons. . Repeat visits at different age levels are required to determine the appropriate time to initiate orthodontic treatment. . Ifprocedure code D8660 is submitted within six months of procedure code D8080, procedure code D8080 will be reduced by the amount that was paid for procedure code D8660. . Procedure code D8680 is payable for one retainer per arch, per lifetime, and each retainer may be replaced once because ofloss or breakage (prior authorization is required).
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. Procedure code D8670 must be submitted only when an adjustment to the appliances is provided and may not be submitted before the date on which the orthodontic adjustment was performed. The number of visits for monthly adjustments to the appliances is restricted to the number that was authorized in the treatment plan. However, the number of monthly visits may be amended with appropriate documentation of medical necessity while the client is Medicaid eligible. . Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless special circumstances exist.
. All orthodontic procedure codes and appliances are global fees.
. Separate fees for adjustments to retainers are Rot payable.
. The appropriate procedure code must be submitted for those appliances required as part of the treatment of cleft palate cases. Special orthodontic appliances may also be used with full banding and crossbite therapy with approval by the TMHP Dental Director. . Procedure codes D5951, D5952,D5953, D5954, D5955, D5958, D5959, and D5960 are to be used as applicable with documentation of medical necessity. Otherwise, use the appropriate special orthodontic appliance code. . Full banding is allowed on permanent dentition only, and treatment should be accomplished in one stage and is allowed once per lifetime.
Exception: Cases of mixed dentition when the treotment Plan íncludes extractions of remainingprimary teeth or cleft palate.
. Crossbite therapy is allowed for primary, mixed, or Permanent dentition. . Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for treating the crossbite to completion, and additional reimbursement is not provided for adjustments or maintenance. . If a case is not approved, the dentist may file a claim for payment of the diagnostic workup for procedure codes used that were necessary to request the prior authorization (procedure codes D0330, D0340, D0350, and D0470). The dentist may receive payment under these procedure codes for no more than two cases out of every ten cases denied. The dentist should determine if the client's condition meets orthodontic benefit criteria before performing a diagnostic workup. . Procedure codes D8080, D8050, and D8060, are limited to one per lifetime. . Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years of age and older or clients who have exfoliated all primary dentition. Crossbite therapy includes diagnostic cast services.
4.2.24.2 Completìon of Treatment Plan If a client reaches 2l years of age or loses Medicaid eligibility before the authorized orthodontic treatment is completed, reimbursement is provided to complete the orthodontic treatment that was authorized and initiated while the client was 20 years of age or younger, eligible for Medicaid THSteps, and completed within 36 months. Any orthodontic-related service requested in the prior authorization request (e.g., extractions or surgeries) must be completed before the loss of client eligibility. Services cannot be added or approved after Medicaid THSteps eligibility has expired.
Exception: Medicøid wíII not reimburse for øny orthodontic services during a period of time when a THSteps client is incarcerated. During a period of incørceration, the facility is responsible for any and all dentøl services, including orthodontic services.
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4.2.24.3 Premature Removol of Applìonces The overall fee for orthodontic treatment (D8080) includes the removal of orthodontic brackets and treatment appliances. Procedure codeD7997 may be used only when the appliances were placed by a different provider with an unaffiliated practice (not a partner or office-sharing arrangement) and one of the following conditions exist: . There is documentation of a lack of cooperation from the client. . The client requests premature removal and a release of liability form has been signed by the parent, guardian, or client ifhe is at least l8 years ofage.
Providers must keep a copy of the release of liability form on file and are responsible for this documen- tation during a review process.
4.2.24.4 Tra n sfe r of Orth od o ntì c S erv ice s Prior authorization that has been issued to a dental provider for orthodontic services is not transferable to another dental provider. The new provider must submit to TMHP a new prior authorization request to get approval to complete the orthodontic treatment that was initiated by the original provider. To complete the treatment plan, the client must be eligible for Medicaid with a current client Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Form H1027). If the client does not return for the completion of services and there is documented failure to keep appointments by the client, the dental provider who initiated the services may submit a claim for reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last DOS.
The following supporting documentation must accompany the new request for orthodontia services and must include the DOS the orthodontic diagnostic tools were completed and include: . All of the documentation as required for the original provider. . The reason the client left the previous provider, if known. . An explanation of the treatment status. . A complete treatment plan addressing all procedures for which authorization is being requested (such as the number of monthly adjustments or retainers required to complete the case).
. A full diagnostic workup (procedure code D8080) with an HLD Index. The score of 26 points will be modified according to any progress achieved.
Exception: The prior authorization requests for clíents who initiate orthodontic services before becoming eligible for Medicaid do not require models or the HLD score sheet, nor does the client have to meet the HLD Index of 26 points. However, a complete plan of treatment is required.
Note: If Medicaid clients initiate orthodontic services outside of Medicaid because they do not score 26 points on the HLD, they øre not eligible to høve their orthodontic services transferred to or reimbursed by Medicaid. Providers who want to request prior authorization to complete orthodontic treatment that was initiated by another provider must complete a THSteps Dental Mandatory Prior Authorization Request Form and send it with the complete plan of treatment, and the appropriate documentation for orthodontic services or crossbite therapy to the TMHP Dental Director at the following address: Texas Medicaid & Healthcare Partnership THSteps Dental Prior Authorization Unit PO Box 202917 Austin, TX78720-2917
cH- I85 CPT ONLY - COPYRICHT 20IO AMERICAN MEDICAL ASSOCIATfON ALL RICHTS RESERVED TEXAS MED]CAID PROVIDER PROCEDURES MANUAL: VOL.2
4,2.24. 5 Co m p reh e n sÍve O rth o dont¡ c Treatm e nt Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years of age and older or clients who have exfoliated all primary dentition. Crossbite therapy includes diagnostic cast services. National procedure codes do not allow for any work-in-progress or partial submission of a claim by separating the three orthodontic components: diagnostic workup, orthodontic appliance (upper), or orthodontic appliance (lower). When submitting claims for comprehensive orthodontic treatment, procedure code D8080, three local codes must be submitted as remarks codes along with procedure code D8080. Local codes (procedure codes22009, Diagnostic workup approved; Z20ll, Orthodontic appliance, upper; orZ20l2, Orthodontic appliance, lower) must be placed in the Remarks Code field on electronic claims or Block 35 on paper claims.
Note: If the remørks code and procedure code D8080 are not submitted, the claim will be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. Procedure code D8080 must be submitted on three separate details, with the appro- priate remarks code, even if the claim submission is for the workup and full banding. Submission of only one detail for a total of 9775 will not be accepted.
Example l: A client is approved for full banding, but after the initial workup, the client discontinues treatment. This provider would submit the national procedure code D8080 and place the local code 22009, Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175.
Example 2: A client is approved for full banding. The provider continues treatment and places the maxillary bands. The provider would submit the national procedure code D8080 and place the local procedure code22009, Diagnostic workup approved, andZ20ll, Maxillary bands, in the Remarks/comment field. The claim would pay $475. All electronic claims for procedure code D8080 must have the appropriate remarks code associated with the procedure code.
Providers must adhere to the following guidelines for electronic claim submission so TMHP can accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three b¡es of the NTE02 at the 2400loop.
Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code22009, enter the information as follows: DPCZ2009. The total submitted would be $175.
Example 2l-For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are 22009 andZ20ll, enter the information as follows: DPCZ2009Z20ll. The total submitted would be $475. Example 3: Fora claim with three details, where all three details are submitted separatelywith procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2009Z20llZ20l2. The total submitted would be $775. This method ensures accurate and appropriate payment for services rendered and addresses the need for submission of a partial claim.
cll 186 CPT ONLY, COPYRICHT 20IO AMERICAN MEDICAL ASSOCIATION ALL RICHTS RESERVED Appendix E ï¡xns Mr0rcnr0 Pnovrorn PR0cEDURES MRHuRT: Vor. 1
Welcomez2Ol0 Texas Medicaid Provider Procedures Manual This manual is a comprehensive guide for Texas Medicaid providers. It contains information about Texas Medicaid benefits, policies, and procedures. It also includes information about Texas Health Steps (THSteps), the Children's Services Program and managed care programs, including Primary Care Case Management (PCCM).
Texas Medicaid policy published in this manual was implemented on or before fanuary l, 2010. Policy updates effective after fanuary 2,2010, are published bimonthly in the Texas Medicaid Bulletin.
All Texas Medicaid policy updates, which are published bimonthly in the Texas Medicaid Bulletin, supplement this manual and update the policy it contains. This manual is also available on the TMHP website at www.tmhp.com.
New Format for 2010 This year's manual features a new format that makes it easier to access the information providers need. The following outlines the new format:
Volume l: General lnformation Volume I applies to all health-care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid clients. The sections in Volume I include general information for enrolling in the program, receiving appropriate reimbursement, and claim submissions and appeals for services rendered. . Contents . Introduction . TMHP Telephone and Address Guide . Section l. Provider Enrollment and Responsibilities . Section 2. Texas Medicaid Reimbursement . Section 3. TMHP Electronic Data Interchange (EDI) . Section 4. Client Eligibility . Section 5. Prior Authorization . Section 6. Claims Filing . Section 7. Appeals . Section 8. Managed Care . Appendix A: State and Federal Offices Communications Guide . Appendix B: Vendor Drug Program . Appendix C: HIV/AIDS . Appendix D: Medical Transportation . Appendix E: Acronym Dictionary . Index (for Volume I and all handbooks)
I CPTONLY, COPYRICHT2OO9AMERICAN MEDICALASSOCIATION ALL RICHTS RESERVED CHILDRENS SERVICES H,{NDBOOK
5.3.23 Hospitalization and ASC/HASC Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may be benefits of THSteps based on the medical or behavioral justification provided, or if one of the following conditions exist: . The procedures cannot be performed in the dental office. . The client is severely disabled.
To satisfr the preadmission history and physical examination requirements of the hospital, ASC, or HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the child's primary care provider. Physicians who are not enrolled as THSteps medical providers should bill for the examination of a client before the procedure with the appropriate evaluation and management procedure code from the following table:
Procedure Code Place of Service (POS) 99202 POS I (office) 99222 POS 3 (inpatient hospital) 99282 POS 5 (outpatient hospital)
Providers enrolled in THSteps Medical should refer to subsection 6.3.1.6, "Exception-to-Periodicity Checkups" in this handbook. Note: The dental provider should bill TMHP using the ADA Dental Claim Form to be considered for reimbursement through THSteps Dental Services. Contact the individual HMO for precertification requirements related to the hospital procedure. If services are precertified, the provider receives a precertification number effective for 90 days.
In those areas of the state with Medicaid managed care, the provider should contact the managed care plan for specific requirements or limitations. It is the dental provider's responsibility to obtain precerti- fication from the client's HMO or managed care plan for facility and general anesthesia services if precertification is required. To be reimbursed by the HMO, the provider must use the HMO's contracted facility and anesthesia provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthe- siologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is the responsibility of the client's primary care provider. The primary care provider must be notified by the dentist or the HMO of the planned services. Dentists providing sedation or anesthesia services must have the appropriate current permit from the TSBDE for the level of sedation or anesthesia provided.
The dental provider must be in compliance with the guidelines detailed in General Information. Note: Post-treatment authorization will not be approved for codes that require mandatory prior authorization.
5.3.24 Orthodontic Services (THSteps) Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid. Orthodontic services are limited to the treatment of children l2 years of age or older with severe handicapping maloc- clusion, children birth through 20 years of age with cleft palate, or other special medically necessary circumstances as outlined in Benefits and Limitations, which follows.
clt-l ól CPT ONLY , (]OPYRICI IT 2OO9 AMERICAN MEDJCAL ÀSSOCIATION AI-L RIGHTS RESERVED TEXAS MEDICA]D PROVIDER PROCEDURES MANUAL: VOL.2
5.3.24.1 BenefÍts and Limitations Orthodontic services include the following: . Correction of severe handicapping malocclusion as measured on the Handicapping Labiolingual Deviation (HLD) Index. Refer to subsection 5.3.26,"How to Score the Handicapping Labio-lingual Deviation (HLD) Index" in this handbook for information on how to score the HLD. A minimum score of 26 points is required for full banding approval (only permanent dentition cases are considered).
Erception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefit from eaily treøtment. Cleft palate cases do not have to meet the HLD 26-point scoring requirement. However, it is necessary to submit a sfficient narrative and/or outline of the proposed treatment plan when requesting authorizøtion for orthodontic services on cleft Palate cases. . Crossbite therapy. . Head injury involving severe traumatic deviation.
The following limitations apply for orthodontic services: . Orthodontic services for cosmetic purposes only are not a benefit of Texas Medicaid or THSteps. . Orthognathic surgery, to include extractions, required or provided in conjunction with the appli- cation of braces must be completed while the client is Medicaid-eligible in order for reimbursement to be considered. . Except for procedure code D8660, all orthodontic procedures require prior authorization for consideration of reimbursement. . The THSteps client must be Medicaid THSteps-eligible when authorization is requested and the orthodontic treatment plan is initiated. It is the provider's responsibility to veri$ that the client has a current Medicaid Identification Form (Form H3087) or Medicaid Eligibility Verification Form (Forms H1027 andHl027-A-C); that the date of birth on the form indicates the client is 20 years of age or younger; and that no limitations are indicated.
. Prior authorization is issued to the requesting provider only and is not transferable to another provider. If the client changes providers or if the provider ceases to be a Medicaid provider for any reason, a new prior authorization must be requested by the new provider.
Refer to: Subsection 5.3.24.4, "Transfer of Orthodontic Services" in this handbook.
The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services under THSteps dental services: . Procedure code D8660 is allowed when: . The client is referred to a dental provider to determine whether orthodontic services are indicated and to determine the appropriate time to initiate such services. . The client is referred to a dental provider and elects to receive services from another orthodontic provider for justifiable reasons. . Repeat visits at different age levels are required to determine the appropriate time to initiate orthodontic treatment. . If procedure code D8660 is billed within six months of procedure code D8080, procedure code D8080 will be reduced by the amount that was paid for procedure code D8660. . Procedure code D8680 is payable for one retaíner per arch, per lifetime, and each retainer may be replaced once because ofloss or breakage (prior authorization is required).
cll- r64 CPT ONLY - COPYRICËIT 2OO9 AJ\4ERICAN MEDICAL ASSOCIATION ALL RIGT]'TS RESERVED CHILDRENS SERVICES HANDBOOK
. Procedure code D8670 should be billed only when an adjustment to the appliances is provided and may not be billed before the date on which the orthodontic adjustment was performed. The number of visits for monthly adjustments to the appliances is restricted to the number that was authorized in the treatment plan. However, the number of monthly visits may be amended with appropriate documentation of medical necessity while the client is Medicaid eligible. . Procedure code D8670 is paid only in conjunction with a history of braces (code D8080), unless special circumstances exist.
. All orthodontic procedure codes and appliances are global fees.
. Separate fees for adjustments to retainers are not payable.
. The appropriate procedure code should be billed for those appliances required as part of the treatment of cleft palate cases. Special orthodontic appliances may also be used with full banding and crossbite therapy with approval by the TMHP Dental Director. . Procedure codes D5951, D5952, D5953, D5954,D5955, D5958, D5959, and D5960 are to be used as applicable with documentation of medical necessity. Otherwise, use the appropriate special orthodontic appliance code. . Full banding is allowed on permanent dentition only, and treatment should be accomplished in one stage and is allowed once per lifetime.
Exception: Cases of mixed dentition when the treatment plan includes extractions of remaining primøry teeth or cleft paløte.
. Crossbite therapy is allowed for primary, mixed, or permanent dentition. . Providers must not request crossbite correction (limited orthodontics) for a mixed dentition client when there is a need for full banding in the adult teeth. Crossbite therapy is an inclusive charge for treating the crossbite to completion, and additional reimbursement is not provided for adjustments or maintenance, . If a case is not approved, the dentist may file a claim for payment of the diagnostic workup for procedure codes used that were necessary to request the prior authorization (procedure codes D0330, D0340, D0350, and D0470). The dentist may receive payment under these procedure codes for no more than two cases out of every ten cases denied. The dentist should determine if the client's condition meets orthodontic benefit criteria before performing a diagnostic workup. . Procedure codes D8080, D8050, and D8060, are limited to one per lifetime. . Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years of age or older or clients who have exfoliated all primary dentition. Crossbite therapy includes diagnostic cast services.
5.3.24.2 Completion of Treatment PIan If a client reaches 2l years of age or loses Medicaid eligibility before the authorized orthodontic treatment is completed, reimbursement is provided to complete the orthodontic treatment that was authorized and initiated while the client was 20 years of age or younger, eligible for Medicaid THSteps, and completed within 36 months. Any orthodontic-related service requested in the prior authorization request (e.g., extractions or surgeries) must be completed before the loss of client eligibility. Services cannot be added or approved after Medicaid THSteps eligibility has expired.
Exception: Medicaid will not reimburse for any orthodontic services during a period of time when a THSteps client is incarcerated. During a period of incarceration, the facílity is responsible for any and all dentøI services, includíng orthodontic seruices.
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5.3.24.3 Premature Removal of Appliances The overall fee for orthodontic treatment (D8080) includes the removal of orthodontic brackets and treatment appliances. Procedure codeD7997 may be used only when the appliances were placed by a different provider with an unaffiliated practice (not a partner or office-sharing arrangement) and one of the following conditions exist: . There is documentation of a lack of cooperation from the client. . The client requests premature removal and a release of liability form has been signed by the parent, guardian, or client ifhe is at least l8 years ofage.
Providers must keep a copy of the release of liability form on file and are responsible for this documen- tation during a review process.
5.3.24.4 Tronsfer of Orthodontìc Services Prior authorization that has been issued to a dental provider for orthodontic services is not transferable to another dental provider. The new provider must submit to TMHP a new prior authorization request to get approval to complete the orthodontic treatment that was initiated by the original provider. To complete the treatment plan, the client must be eligible for Medicaid with a current client Medicaid Identification Form (Form H3087) or Medicaid EligibilityVerification Form (Form H1027). If the client does not return for the completion of services and there is documented failure to keep appointments by the client, the dental provider who initiated the services may submit a claim for reimbursement. The claim must be received by TMHP within the 95-day filing deadline from the last DOS.
The following supporting documentation must accompany the new request for orthodontia services and must include the DOS the orthodontic diagnostic tools were completed and include: . AII of the documentation as required for the original provider. . The reason the client left the previous provider, if known. . An explanation of the treatment status. . A complete treatment plan addressing all procedures for which authorization is being requested (such as the number of monthly adjustments or retainers required to complete the case).
. A full diagnostic workup (procedure code D8080) with an HLD Index. The score of 26 points will be modified according to any progress achieved.
Exception: The prior authorization requests for clients who initiate orthodontic services before becoming eligible for Medicaid do not require models or the HLD score sheet, nor does the client høve to meet the HLD Index of 26 points. However, a complete plan of treatment is required.
Note: If Medicaid clients initiate orthodontic services outside of Medicaid because they do not score 26 points on the HLD, they are not eligible to have their orthodontic services transferred to or reimbursed by Medicaid. Providers who want to request prior authorization to complete orthodontic treatment that was initiated by another provider must complete a THSteps Dental Mandatory Prior Authorization Request Form and send it, the complete plan of treatment, and the appropriate documentation for orthodontic services or crossbite therapy to the TMHP Dental Director at the following address: Texas Medicaid & Healthcare Partnership THSteps Dental Prior Authorization Unit PO Box 202917 Austin, TX78720-2917
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5,3,24.5 Comprehensìve Orthodontic Treatment Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are l2 years of age or older or clients who have exfoliated all primary dentition. National procedure codes do not allow for any work-in-progress or partial billing by separating the three orthodontic components: diagnostic workup, orthodontic appliance (upper), or orthodontic appliance (lower).
When billing for comprehensive orthodontic treatment, procedure code D8080, three local codes must be submitted as remarks codes along with procedure code D8080. Local codes (procedure codes22009, Diagnostic workup approved; Z20ll, Orthodontic appliance, upper; or Z2Ol2, Orthodontic appliance, lower) must be placed in the Remarks Code field on electronic claims or Block 35 on paper claims. Note: lf the remarks code and procedure code D8080 are not submitted, the claim wiII be denied.
Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. Procedure code D8080 must be billed on three separate details, with the appropriate remarks code, even if billing for the workup and full banding. Billing only one detail for a total of $775 will not be accepted. Example l: A client is approved for full banding, but after the initial workup, the client discontinues treatment. This provider would bill the national procedure code D8080 and place the local code 22009, Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175. Example 2: A client is approved for full banding, The provider continues treatment and places the maxillary bands. The provider would bill the national procedure code D8080 and place the local procedure code 22009, Diagnostic workup approved, and Z2Oll , Maxillary bands, in the Remarks/comment field. The claim would pay $475. All electronic claims for procedure code D8080 must have the appropriate remarks code associated with the procedure code.
Providers should adhere to the following guidelines for electronic claim submission so that TMHP can accurately apply the correct remarks code to the appropriate claim detail.
A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the fìrst three b¡es of the NTE02 at the 2400 loop. Example l: For a claim with one detail, submitted with procedure code D8080 and remarks code22009, enter the information as follows: DPCZ2009. The total billed would be $175.
Example 2: For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are 22009 andZ20l l, enter the information as follows: DPCZ2009Z20l l. The total billed would be $475. Example 3: For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2009Z20||Z2Q|2. The total billed would be $775. This method ensures accurate and appropriate payment for services rendered and addresses the need for partial billing.
cÐ-167 CPT ONLY - (:OPYRICIIT 2OO9 AIVf IiIì,I(]AN ì\4EDICAL,ASSOC¡ATION ALL RI(;HTS RESERVED TEXAS MEDICAID PIì.OVIDER PROCEDUIìES MANUAL: VOL 2
5.3,24,6 Orthodontic Procedure Codes and Fee Schedule When submitting claims for orthodontic procedures, use the following procedure codes:
Procedure Code Limitations Maximum Fee Orthodontic Services D0330*, When requested orthodontic cases are submitted for authorization $ 100.00 D0340*, and denied, two out of ten denials will be paid. These four D0350*, and procedure codes, when billed together for denied cases, replace D0470* local procedure code 22010. D7280 A 1-20 $62.s0 D7997* Replaces 22016. Not payable to the dentist who placed the $s0.00 appliance. Includes removal of arch bar and premature removal of braces. A l-20
D8050* Replaces Z2OIB and 8l l0D. Limited to one per lifetime. $340.00 D8060* Replaces 22018 and 8120D. Limited to one per lifetime. $340.00
D8080* Replaces 22009, Z20ll, and 22012. Limited to one per lifetime $77s.00
D8210* Refer to Subsection 5.3.25, "Special Orthodontic Appliances" below See separate for associated remarks field code. table D8220x Refer to Subsection 5.3.25, "Special Orthodontic Appliances" below See separate for associated remarks field code. table
D8660* Replaces 22008. Denied when billed on the same DOS as D0120, $ 15.00 D0145, or D0150. D8670* Replaces 22013. $68.10 D8680* Replaces 22014 and 22015; one retainer per arch per lifetime; may $ 100.00 be replaced once because ofloss or breakage (prior authorization is required). D8690* Bracket replacement. $20.00 D8691 Not considered medically necessary NC D8692 Although procedure code D8692 is not a benefit of Texas Medicaid, NC providers can use procedure code D8680 to bill for retainer(s). Providers should include local code 22014 or 22015 on the claim form to indicate upper or lower, as appropriate. D8693 $s0 00 D8999 Manually p riced + for = Services payable to an FQHC a client encounter,
5.3.25 Special Orthodontic Appliances All rernovable or fixed special orthodontic appliances rnust be prior authorized. The prior authorization request musl" include both the national code and remarks code. However, prior authorization requests may omit the DPC prefix to the eight-digit remarks code.
CI I I6{J (lPlONl-\'(iOP\l{l(itll2Ur)9r\IIl,l{l(i,\NÀll,l)l(i?\l r\SSO(ll,\llON^llftl(ìlllSltf,Sl:R\/Ct) Appendix F Dear Manual User: Welcome to the 2009 Texas Medicaid Provider Procedures Manual. To enhance usability, this manual is available on a searchable CD-ROM and on the TMHP website at www.tmhp.com. Note: Alt users who access www,tmhp.com are requìred to accept the American Medical Association (AMA) End-user Agreement on the use of Current Procedural Terminology (CPT). For each computer that accesses the TMHP website, the agreement must be accepted every 30 days from the last date on which the agreement was accepted by the user. lf the end-user agreement is not accepted on a particular computer every 30 days, no user will be able to enter the webs¡te from that computer, For additional information about the AMA and CPT, refer to www.ama-assn.org/ama/pub/category /3113.htm\. A Ctaims Fiting Resources table is located at the end of each service section with page references to all claim instructions, appendices, Medicaid forms, and claim form examples associated with the service. This manual contains both the Primary Care Case Management (PCCM) and Texas Health Steps (THSteps) manuals. PCCM information can befound primarily in Section 7, though relevant information can be found in othersections. THSteps information is contained in Section 43 and throughoutthe manual. Texas Medicaid policy published ¡n this manual represents policy implemented on or before October 31, 2008. Policy updates effective after October 31, 2008, are published bimonthly in the lexas Medicaid Bulletin. The November/December 2OO8 Texas Medicaid Bulletin and all Texas Medicaid Bulletins through and including the September/October 2OO9 Texas Medicaid Bulletin supplement the 2009 Texas Medicaid Provider Procedures Manual and update the policy contained herein. The Texas Medicaid Provider Procedures Manualserves as a comprehensive guide for Texas Medicaid providers, and contains information aboutTexas Medicald benefits, policies, and procedures. The manual also includes an overview of the State of Texas Medicaid Managed Care programs to include the State of Texas Access Reform (STAR), STAR+PLUS, PCCM, and NorthSTAR. The information regarding the State of Texas Medicaid Managed Care programs, including Section 7, is not an exhaustive policies and procedures guide. Forspecific managed care information, contactthe individual health plans participating in STAR, STAR+PLUS, and NorthSTAR. For PCCM, refer to the TMHP Telephone and Address Guide included in this manual.
Provider Manual Overview The 2008 Texas Medicaid Provider Procedures Manual is divided into three pafts, including:
Part l: Provider lnformation The information in Part I is for all health-care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid clients. ln Part l, providers find instructions for providing allowable services and receiving appropriate reimbursementforservices. The followingsections are included in Part l: . lntroduction . TMHP Telephone and Address Guide . Section 7. Provider Enrollment and Responsibilitles . Section 2. Texas Medicaid Reimbursement . Section 3. TMHP Electronic Data lnterchange (EDl) . Section 4. Client Eligibility . Section 5. Claims Flling . Section 6. Appeals . Section Z. Managed Care
Part ll: Texas Medicaid Services Parl ll contains a section for each Texas lvledicaid service with information on health-care policy, proce- dures, and claims filing peftaìning to each provìder type.
CP-f on y coDynght 2008 American il,4edical Assoclation All rrghts reserued Provider Enrollment and Responsibilities
should allow longer than "at the time of the request" to Once a provider receives the request for medical records, produce the records, the provider will be required to the provider must submit the information electronically or produce all records completed, at the time of the in hard copy within 60calendar days. lt is important that completion or at the end of each day of product¡on, as providers cooperate by submitting all requested documen- directed by the requestor who will take custody of the tation in a timely manner because no response or requested ¡tems. insufficient documentation will count against the state as an error. This can ultimately negatively impact the amount lf the provider places the required information in another of federal funding received by Texas for Medicaid. legal entity's records, such as a hospital, the provider is responsible for obtaining a copy of these requested records for use by the requesting state and federal agencres. t.4.4 Release of Gonfidential Information lnformation about the diagnosis, evaluation, or treatment These documents and claims must be retained for a of a client with Texas Medicaid coverage by a person minimum period of five years from the date of service or licensed or certified to perform the diagnosis, evaluation, until all aud¡t questions, appeal hearings, investigations, or treatment of any medical, mental, or emotional or court cases are resolved. Freestanding RHCs must disorder, or drug abuse, is confidential informat¡on that retain their records for a minimum of six years, and the provider may disclose only to authorized people. hospital-based RHCs must retain their records for a Family planning information is sensitive, and confidenti- minimum of ten years. These records must be made ality must be ensured for all clients, especially minors. available immediately at the time of the request to employees, agents, or contractors of HHSC Office of Only the client may give written permission for release of lnspector General (OlG), the Texas Attorney General's any pertinent information before client information can be Medicaid Fraud Control Unit (MFCU) or Antitrust and Civil released, and confidentiality must be maintained in all Medicaid Fraud Section, TMHP, DFPS, the Department of other respects. lf a client's medical records are requested Aging and Disability Services (DADS), Department of State by a licensed Texas health-care provider or a physician Health Services (DSHS), Department of Assistive and licensed by any state, territory, or insular possession of Rehabilitative Services (DARS), U.S. Department of Health the United States or any State or province of Canada, for and Human Services (HHS) representative, any state or purposes of emergency or acute medical care, a provider federal agency authorized to conduct compliance, must furnish such records at no cost to the requesting regulatory, or program ¡ntegrity functions on the provider, provider. This includes records received from another person, or the services rendered by the provider or physician or healthcare provider involved in the care or person, or any agent, contractor, or consultant of any treatment of the patient. lf the records are requested for agency or division delineated above. ln addition, the purposes other than for emergency or acute medical care, provider must meet all requirements of 1 TAC, Part 15, the provider may charge the requesting provider a s371.1643(f). reasonable fee and retain the requested information until payment is received. The records must be available as requested by each of these entities, during any investigation or study of the The client's signature is not required on the claim form for appropriateness of the Medicaid claims submitted by the payment of a claim, but HHSC recommends the provider provider. obtain written authorization from the client before releasing confidential medical information. A release may be obtained by having the client sign the indicated block 1".4.3.L Payment Error Rate Measurement on the claim form after the client has read the statement (PERM) Process of release of information that is printed on the back of the form. The client's authorization for release of such infor- CMS assesses Texas Medicaid using the PERM process mation is not requ¡red when the release is requested by to measure improper payments in Texas Medicaid. and made to DADS, HHSC, DSHS, TMHP, DFPS, DARS, Providers will be required to provide medical record HHSC OlG, the Texas Attorney General's MFCU or documentation to support the medical reviews that the Antitrust and Civil Fraud Division, or HHS. federal review contractor will conduct for Texas Medicaid fee-for-service and PCCM Medicaid and State Children's Health lnsurance Program (SCHIP) claims. L.4.5 Compliance w¡th Federal Legislation Under the PERM process, if a claim is selected in a HHSC complies with HHS regulations that protect aga¡nst sample for a service that a provider rendered to a discrimlnation. All contractors must agree to comply with Medicaid client, the provider will be contacted to submit a the following: copy of the medical records that support the medical review of the claim. All providers should check the TMHP . Title Vl of the Civil Rights Act of 1964 (Public Law system to ensure their current telephone number and 88-352), Section 504 of the Rehabilitation Act of 1 97 3 addresses are correct in the system. lf the information is (Public Law 93-!t2), The Americans with Disabilities Act incorrect or incomplete, providers must request a change of 1990 (Public Law 101-336), Title 40, Chapter 73, of immediately to ensure the PERM medical record request the TAC, all amendments to each, and all requirements can be delivered. Client authorization for release of this imposed by the regulations issued pursuant to these information is not required. acts. The laws provide in pari that no persons in the
CPT only copyright 2008 Ameícan ¡/edical Association. All rights reseryed 1_-L3 Section 1
U.S. shall, on the grounds of race, color, nationalorigin, fully compliant with all three categories of the tamper- age, sex, disability, political beliefs, or religion, be resistant regulations, provided they contain at least one excluded from pafticipation in or denied any aid, care, feature from each of the three following categories: service, or other benefits provided by federal and/or . Prevents unauthorized copying of completed or blank state funding, or otherwise be subjected to any prescription forms. discrimination . Prevents erasure or modification of information written . HealthandSafetyCode85.1'l 3as described in "Model on the prescription form. Workplace Guidelines for Businesses, State Agencies, and State Contractors" on page G-2 (relating to . Prevents the use of counterfeit prescription forms. workplace and confidentiality guidelines on AIDS and Hlv) 1,.4.7 Utilization Control - General Exception: ln the case of minors receiving family planning Provisions services, only the client may consent to release of medical Title XIX of the Socla/ Security Act, Sections 1902 and documentation and information. Providers must comply with the laws and regulations concerning discrimination. 1903, mandates ut¡l¡zation control of all Texas Medicaid Payments for services and supplies are not authorized services under regulations found at Title 42 CFR, Part unless the services and supplies are provided w¡thout 456. Utilization review activities required by Texas Medicaid are completed through a series of monitoring discrimination on the bas¡s of race, color, sex, national systems developed to ensure the quality of services origin, age, or disability. Send written complaints of provided, and that all services are both medically noncompliance to the following address: necessary and billed appropriately. Both clients and HHSC Commissioner providers are subject to utilization review monitoring. Utili- 1100 West 49th Street zat¡on control procedures safeguard against the delivery Austin, TX787563L72 of unnecessary services, monitor quality, and ensure Reminder: Each provider must furnish covered Medicaid payments are appropriate and according to Texas services to eligible clients in the same manner, tothe same Medicaid policies, rules, and regulations. All providers extent, and of the same quality as services provided to identified as a result of utilization control activities are other patients. Services made available to other pat¡ents presented to HHSC OIG to determine any and all subse- must be made available to Texas Medicaid clients if the quent actions. services are benefits of Texas Medicaid. The primary goal of utilization control activity is to identify providers with practice patterns inconsistent with the federal requirements and Texas Medicaid scope of L.4.6 Tamper-Resistant Prescription Pads benefits, policies, and procedures. The use of utilization Providers are required by federal law (Public Law 110-28) control monitoring systems allows for identification of to use a tamper+esistant prescription pad when writing a providers whose patterns of practice and use of services prescription for any drug for Medicaid clients. fall outside of the norm for their peer groups. Providers identified as exceptional are subject to an indepth review Providers must take necessary steps to ensure that of all Texas Medicaid billings. These review findings are tamper-resistant pads are used for all written prescrip- presented to the HHSC OIG to determine any necessary tions provided to Medicaid cl¡ents. Providers may also use action. Medical records may be requested from the com plia nt, non-written alternatives for tra ns m¡tting provider to substantiate the medical necessity and appro- prescriptions such as by telephone, fax, or electronic priateness of services billed to Texas Medicaid. submittal. Pharmacies are required to ensure that all lnappropriate service utilization may result in recoupment written Medicaid prescriptions submitted for payment to of overpayments and/or sanctions, or other adminis- the Vendor Drug Program are written on a compliant trative actions deemed appropriate by the HHSC OlG. tamper-resistant pad. There are instances when a training specialist may be lf a prescription is not submitted on a tamper-resistant directed to communicate with the provider to offer assis- prescription form, a pharmacy may fill the prescription in tance with the technical or administrative aspects of full on an emergency basis. Texas Medicaid. The pharmacy must then obtain a verbal, faxed, Atthe direction of the HHSC OlG, a provider's claims may electronic, or compliant, written prescription from the be manually reviewed before payment. Parameters are prescriber within 72 hours after the date on which the developed for prepayment review based on the specific prescription was filled. areas of concern identified in each case. As part of the Providers may pu rchase ta mper-res ista nt prescri ption prepayment review process, providers are required to pads from the vendor of their choice. submit paper claims, ratherthan electronic claims, along with supporting medical record documentation (e.9., Special copy+esistant paper is not a requirement for clinical notes, progress notes, diagnostic test¡ng results, prescriptions printed from electronic medical records other reports, superbills, X-rays, and any related medical (EMRs) or ePrescribing generated prescriptions. These record documentation) attached to each claim for all prescriptions may be printed on plain paper and will be services billed. This documentation is used to ascerta¡n that the services billed were medically necessary, billed
L-L4 CPT only copyright 2008 American N4edical Association All rights reserued Denta I
L9.4.2 THSteps Dental Eligibility . Dental prophylaxis, if appropriate The client must be Medicaid- and THSteps-eligible (birth . Topical fluoride application using fluoride varnish, if through 20 years ofage) atthe time ofthe service request appropriate and service delivery. However, Medicaid-approved . Caries risk assessment orthodontic services already in progress may be continued . Dental anticipatory guidance even after the client loses Medicaid eligibility if the orthodontic treatment is begun before the loss of Procedure code D0145 bundles the above services for Medicaid eligibility and before the day of the client's 21st THSteps clients age 6 months of age through 35 months birthday and is completed within 36 months. Medicaid- of age. THSteps dentists and Federally Qualified approved orthodontic services already in progress may be Healthcare Centers (FQHCs) that have completed training continued even afterthe client loses Medicaid eligibility if and been certified to participate in the First Dental Home the orthodontic treatment is: initiative may be reimbursed for procedure code D0145. . FQHC providers attending the training will be certified at Begun before the loss of Medicaid eligibility the facility level. . Begun before the day of the client's 21st birthday Procedure code D0120, D0150, Dtt2O, D1203, or . Completed within 36 months. DL206 are denied if procedure code D0145 is billed on The client is not eligible for THSteps dental preventive or the samê date of service by any provider. A First Dental therapeutic benefits if the client's Medicaid ldentification Home examination is limited to ten services per client Form (Form H3087) or Medicaid Eligibility Verification lifetime with at least 60 days between visits. This service Form (Forms H7O27 and HLO27-A-C) states any of the is limited to once per day. following: . Emergency care only . Presumptive eligibility (PE) 19.5 ICF-MR Dental Services ICF-MR dental services are mandated by Medicaid, and . Qualified Medicare beneficiary (QMB) reimbursement is provided for treatment of dental . Women's Health Program problems for Medicaid-eligible residents of ICF-MR facil- A check mark will be present ¡n the "Dental" column of the ities who are 2tyears of age or older. Residents of ICF-MR client's Medicaid ldentification Form (Form H3087) to facilities who are 20 years of age or younger receive indicate that the client is eligible for dental services. A services through the regular THSteps Program. Eligibility message (THSteps Dental checkup due) may appear for ICF-MR services is determined þy DADS. below the client's name on the monthly client Medicaid Procedure codes without a CCP designation in the limita- ldentification Form (Form H3087) statingthe client is due tions column of the dental fee schedule may be billed in a for a dental checkup, which serves as a reminder to routine manner for ICF-MR clients. parents to contact their child's dentist and schedule an These procedures must be documented as medically appointment for their periodic dental checkup. This necessary and appropriate. ICF-MR clients are not subject message is printed on the H3087 when the client has not to periodicity for preventive care. received any dental services (diagnostic, preventive, therapeutic, or orthodontic) for a period of six months. For procedure codes with a CCP designation, a provider may request authorization with documentation or provide Clients are not eligible for CCP services on or after their documentation on the submitted claim. 21st birthday, but are eligible for non{CP THSteps dental services (see fee schedule for CCP and nonCCP Refer to: "Medicaid Dental Fee Schedule" on page 19-11. reimbursed services)through the end of the month of their 21st birthday. Note: lf a client has a birthday on any day except the first 19.6 THSteps and ¡CF-MR Provision day during the month, the new eligibility period is of Services considered to begin on the first day of the following All THSteps and ICF-MR dental services shall be month. peformed by the Med icaid-en rol led denta I provide r except for permissible work delegated to a licensed dental hygienist, dental assistant, or dental technician in a L9.4.3 First Dental Home dental laboratory on the premises where the dentist First Dental Home is an initiative designed to establish a practices, or in a commercial laboratory registered with dental home, provide preventive care, identify oral health the Texas State Board of Dental Examiners (TSBDE). The problems, and provide treatment and parenlal/ guardian Texas Dental Practice Actand the rules and regulations of oral health instruct¡ons as early as possible. the TSBDE (22f AC, Part 5) define the scope of work that dental auxiliary personnel may perform. Any deviations A First Dental Home visit includes, but is not limited to: from these practice limitations shall be reported to the . Comprehensive oral examination TSBDE and HHSC, and could result in sanctions or other . Oral hygiene instruction with primary caregiver actions imposed agalnst the provider.
CDf only copyíght 2008 American Dental Association- All rights reseryed 19-5 Section 19
19.18 Hospitalization and ASG/HASC Exception: Retained deciduous teeth and cleft palates with gross malocclusion that will benefit from early Dental services performed in an ASC, hospital ambulatory treatment. Cleft palate cases do not have to meet the HLD surgical center (HASC), or a hospital (either as an 26-point scoring requirement. However, it is necessary to inpatient or an outpatient) may be benefits of THSteps submit a sufficient narrative and,/or outline of the based on the medical or behavioraljustification provided, proposed treatment plan when request¡ng authorization or if one of the following conditions exist: for orthodontic services on cleft palate cases, . The procedures cannot be performed in the dental . Crossbite therapy. office. . . Head injury involving severe traumatic deviation. The client is severely disabled. The following l¡mitat¡ons apply for orthodontic services: Contact the individual HMO for precertification require- ments related to the hospital procedure. lf services are . Orthodontic services for cosmetic purposes only are precertified, the provider receives a precertification not a benefit of Texas Medicaid or THSteps. number effective for 90 days. . Orthognathic surgery, to include extractions, required or ln those areas of the state with Medicaid managed care, provided in conjunction with the application of braces the provider should contact the managed care plan for must be completed while the client is Medicaid-eligible specific requirements or limitations. lt is the dental in order for reimbursement to be considered. provider's responsibility to obtain precertification from the . Except for D8660, all orthodontic procedures require client's HMO or managed care plan for facility and general prior authorization for consideration of reimbursement. anesthesia services if it is required. . The THSteps client must be Medicaid/THSteps€ligible To be reimbursed by the HMO, the provider must use the when authorization is requested and the orthodontic HMO's contracted facility and anesthesia provider. These treatment plan is initiated. lt is the provider's responsi- services are included in the capitation rates paid to bility to see that the client has a current Medicaid HMOs, and the facility/anesthesiologist risk nonpayment ldentification Form (Form H3087) or Medicaid Eligibility from the HMO without such approval. Coordination of all Verification Form (Forms HLO27 and H1O27-A-C) and specialty care is the responsibility of the client's primary that the date of birth on the form indicates the client ¡s care provider. The primary care provider must be notified 20 years of age or younger and no limitations are bythe dentist and/or the HMO of the planned services. indicated. Dentists providing sedation/anesthesia services must . Prior authorization is issued to the requesting provider have the appropriate current permit from the TSBDE for only and is not transferable to another provider. lf the the level of sedation/anesthesia provided. client changes providers or if the provider stops The dental provider must be in compliance with the guide- practicing dentistry in Texas Medicaid for whatever lines detailed in "Dental Therapy Under General reason, a new prior authorization must be requested. Anesthesia" on page 19-35. Refer to: "Transfer of Orthodontic Services" on page 19- Note: Post-treatment authorization will not be approved 40. for codes that require mandatory prior authorization. The following procedure codes, policies, and limitations are applied to the processing and payment of o¡thodontic services under THSteps dental services: 19.19 Orthodontic Services . Procedure code D8660 is allowed when: (THSteps) . The client is referred to an ofthodontistfora determi- Orthodontic services for cosmetic purposes only are not a nation of whether orthodontic services are indicated benefit of Texas Medicaid. Orthodontic services are and to determine the appropriate time to initiate limited to the treatment of children t2years of age or such services. older with severe handicapping malocclusion, children . The client is referred to an ofthodontist and elects to birth through 20 years of age with cleft palate, or other receive services from another orthodontic provider special medically necessary circumstances as outlined in because of justifiable reasons. Benefits and Lim¡tations below. . Repeat visits at different age levels are required to determine the appropriate time to initiate 19.19.1 Benefits and Limitations orthodontic treatme nt. Orthodontic services include the following: . Procedure code D8680 is payable for one retainer per arch, per lifetime, and each retainer may be replaced . Correction of severe handicapping malocclusion as once because of loss or breakage (prior authorization is measured on the Handicapping Labiolingual Deviation required). (HLD) lndex. Refer to page 79-45 for information on how to score the HLD. A minimum score of 26 points is . Procedure code D8670 should be billed only when an required for full banding approval (only permanent adjustment to the appliances is provided and may not dentition cases are considered). be billed before the date the orthodontic adjustment was performed. The number of visits for monthly adjust-
19-38 CDf only copyright 2O08 American Denta¡ Assoc¡at¡on All righls reseryed Dental
ments to the appliances is restricted to the number L9.L9.2 Mandatory Prior Authorization that was authorized in the treatment plan. However, the Prior authorization is required for all THSteps orthodontic number of monthly visits may be amended with appro- services except for procedure code D8660. The prior priate documentation of medical necessity while the authorization request must contain the DOS that the client is Medicaid eligible. orthodontic diagnostic tools were produced. lf the request . Procedure code D8670 is paid only in conjunction with is approved, the date that the records were produced is a history of braces (code 08080), unless special considered to be the date on which orthodontic treatment circumstances exist. begins. . All orthodontic codes and appliances are global fees. Refer to: "THSteps Dental Mandatory Prior Authorization . Request Form" on page 8-111. Separate fees for adjustments to retainers are not payable. lf orthodontic treatment is medically indicated, providers . The appropriate code should be billed for those appli- are responsible for obtaining prior authorization for a ances required as part of the treatment of cleft palate complete orthodont¡c treatment plan while the client is cases. eligible for Medicaid and THSteps and 20 years of age or younger. Special orthodontic appliances may also be used with full banding and crossbite therapy with approval by the TMHP Submission of diagnostic casts are not required when Dental Director. requesting prior authorization for procedure codes 08050, D8060, or D8080. . Procedure codes D5951, 05952, D5953, D5954, Prior authorization is a condition for reimbursement; it is D5955, D5958, D5959, and D5960 are to be used as applicable with documentation of medical necessity. not a guarantee of payment. Otherwise, use the appropriate special orthodontic Upon receipt of prior authorization of complete treatment appliance code. plans, providers are to advise clients that they will be able . Full banding is allowed on permanent dentition only, to receive the approved treatment services (e.9. and treatment should be accomplished in one stage orthodontic adjustments, bracket replacements and and is allowed once per lifetime. retainers), even if they lose Medicaid elieiibility or reach 27 years of age. Approved ofthodontic treatment must be Exception: Cases of mixed dentition when the treatment initiated before the loss of Medicaid eligibility and plan includes extractions of remaining primary teeth or completed within 36 months of the authorization date. cleft palate. Note: Providers must submit all orthodontic services for . Crossbite therapy is allowed for primary, mixed, or Medicaid managed care clients following these guide' permanent dentition. lines. STAR and STAR+PLUS are not responsible for . Providers must not request crossbite correction (limited orthodontic services. orthodontics) for a mixed dentition client when there is Requests for orthodontic services must be accompanied a need for full banding in the adult teeth. Crossbite by all of the following documentation: therapy is an inclusive charge for treating the crossbite . An orthodontic treatment plan. The treatment plan to complet¡on, and additional reimbursement is not provided for adjustments or maintenance. must include all procedures required to complete full treatment (such as, extractions, ofthognathic surgery, . lf a case is not approved, the dentist may file a claim upper and lower appliance, monthly adjustments, ant¡c- for payment of the diagnostic workup necessary to ipated bracket replacements, appliance removal if obta¡n the authorization using procedure codes D0330, indicated, special orthodontic appliances, etc.). The D0340, D0350, and D0470. The dentist may receive treatment plan should incorporate only the minimal payment underthese procedure codes for no more than number of appliances required to properly treat the two cases out of every ten cases denied. The dentist case. Requests for multiple appliances to treat an should determine if the client's condition meets individual arch are reviewed for duplication of purpose. orthodontic benefit criteria before performing a . Cephalometric radiograph with tracing models. diagnost¡c workup. . . Completed and scored HLD sheet with diagnosis of Procedure codes D8080, D8O5O, and 08060, are Angle class (26 points required for approval of noncleft limited to one per lifetime. palate cases). . Comprehensive orthodontic services (procedure code . Facial photographs. D8080) are restricted to clients who are !2 years of age or older or clients who have exfol¡ated all primary . Full series of radiographs or a panoramic radiograph; dentition. Crossbite therapy includes diagnosic cast diagnosticauality films are required (copies are services. accepted and radiographs will not be returned to the provider).
CDT only copyright 2008 American Dental Association All rjghls reseryed 19-39 Section 19
. Any additional pertinent information as determined by The following supporting documentation must accompany the dent¡st or requested by TMHP's Dental Director the new request for orthodontia services and must include Requests for crossbite therapy require properly the DOS the ofthodontic diagnostic tools were produced: trimmed models to be retained in the office and must . All of the documentation as required for the original demonstrate the following criteria: provider. . Posterior teeth. Not end to end, but buccal cusp of . The reason the client left the previous provider, if upper teeth should be lingual to buccal cusp of lower known. teeth. . An explanation of the treatment status. . Anterior teeth. The incisal edge of upper should be . lingual to the incisal of the opposing arch. A compete treatment plan addressing all procedures for which authorization is being requested (such as the The dentist should be certain that radiographs, photo- number of monthly adjustments or reta¡ners required to graphs, and other information are properly packaged to complete the case). avoid damage. TMHP is not responsible for lost or damaged materials. . A full diagnostic workup (D8080) with an HLD lndex. The score of 26 points will be modified according to any Refer to: "THSteps Dental Mandatory Prior Authorization progress achieved. Request Form" on page 8-111. Exception:The prior authorization requests for clients who initiate orthodontic services before becoming eligible 19.19.3 Gompletion of Treatment Plan for Medicaid do not requ¡re models or the HLD score sheet, nor does the client have to meet the HLD lndex of lf a client reaches 2tyears of age or loses Medicaid eligi- 26 points, However, a complete plan of treatment is bility before the authorized orthodontic treatment is required. completed, reimbursement is provided to complete the orthodontic treatment that was authorized and initiated Note: Medicaid clients who initiate orthodontic services while the client was 20 years of age or younger, eligible for privately (e.9. pay out of pocket for the ofthodontic workup Medicaid and THSteps, and completed within 36 months. and/or ¡n¡t¡al banding, etc.) wh¡le Medicaid eligible due to Any orthodontic-related service requested (e.9., extrac- not meeting the HLD index 26-points, are not eligible to tions or surgeries) must be completed before the loss of have their orthodontic services transferred to and client eligibility. Serv¡ces cannot be added or approved reimbursed by Medicaid. after Medicaid/THSteps eliÉibility has expired. To request prior authorization for completion of the orthodontic treatment initiated by another provider, complete a THSteps Dental Mandatory Prior Authorization L9.L9.4 Premature Removal of Appliances Request Form and send it with the complete plan of The overall fee for orthodontic treatment (D8080) treatment and appropriate documentation for orthodontic includes the removal of orthodontic brackets and/or services and/or crossbite therapy to the TMHP Dental treatment appliances. Procedure code D7997 may be Director at the following address: used only when the appliances were placed by a different Texas Medicaid & Healthcare Partnership provider with an unaffiliated practice (not a partner or THSteps and ICF-MR Dental Authorization and lnformation office-sharing arrangement) and one of the following PO Box 2O29L7 conditions exist: Austin, TX 78720-2977 . There is documentation of a lack of cooperation from the client. . The client requests premature removal and a release 19.19.6 Gomprehens¡ve Orthodontic form has been signed by the parent, guardian, or client Treatment if he is at least 18 years of age. Comprehensive orthodontic services (procedure code D8080) are restricted to cl¡ents who are t2years o1 age Providers must keep a copy of the release form on file and or older or clients who have exfoliated all primary are responsible for this documentation during a review dent¡tion. process. National procedure codes do not allow for any work-in- progress or partial billing by separating the three 19.19.5 Transfer of Orthodontic Services orthodontic components: diagnostic workup, orthodontic Prior authorization issued to a dental provider for appliance (upper), or orthodontic appliance (lower). orthodontic services is not transferable to another dental When billing for comprehensive orthodontic treatment, provider. The new provider must subm¡t to TMHP a new D8080, three local codes must be submitted as remarks prior authorization request in order to be approved to codes along with code D8080. Local codes (72OO9, complete the orthodontic treatment initiated by the Dia gnostic worku p a pproved, Z2OI1-, O rthodontic original provider.
19-40 CDf only copyright 2008 Ame.ican Dental Association. All rights reseryed De nta I
appliance, upper, or Z2OL2, Orthodontic appliance, lower) are placed in the Remarks Code field on electronic claims or Block 35 on paper claims. Note: lf the remarks code and procedure code D8080 are not subm¡tted, the claim will be denied. Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. D8080 must be billed on three separate details, with the appropriate remarks code, even if billing for the workup and full banding. Billing only one detail for a total of $775 will not be accepted. Example 1: A client is approved forfull banding, but afterthe initial workup, the client discontinues treatment. This provider would billthe national code D8080 and place the local code 22009, Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175. Example 2: A client is approved forfull banding. The provider continues treatment and places the maxillary bands. The provider would bill the national procedure code D8080 and place the local code Z2OO9, Diagnostic workup approved, and 2201,1, Maxillary bands, in the Remarks/comment field. The claim would pay $475. All electronic claims for D8080 must have the appropriate remarks code associated with the procedure code. Providers should adhere to the following guidelines for electronic claim submission so that TMHP can accurately apply the correct remarks code to the appropriate claim detail. A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three bytes of the NTE02 at the 2400 loop. Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code Z2OO9, enter the information as follows: DPCZ2OO). The total billed would be $175. Example 2=For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are Z2OO9 andZ2Ott, enter the information as follows: DPCZ2OO9Z2011. The total billed would be $475. Example 3: Fora claim with three details, where all three details are subm¡tted separatelywith procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2OO972OI7Z2O72. The total billed would be $775. This method ensures accurate and appropriate paymentforservices rendered and addresses the need for partial billing.
L9.L9.7 Orthodontic Procedure Codes and Fee Schedule When submitting claims for orthodontic procedures, use the following procedure codes Procedure Code' Limitations Maximum Fee
D0330*, When requested ofthodontic cases are subm¡tted for authorization $100.00 D0340*, and denied, two out of ten denials will be paid. These four D0350*, and procedure codes, when billed together for denied cases, replace DO470* local procedure code Z2OLO. D7280 A t-20 $62.50 D7997* Replaces Z2016. Not payable to the dentist who placed the $50.00 appliance. lncludes removal of arch bar and premature removal of braces. A 1--2O lnterceptive OrthodontÍc Treatment D8050* Replaces Z2OI8 and 8110D. Limited to one per lifetime. $340.00 D8060* ' Replaces Z2OI8 and 8120D. Limited to one per lifetime. $340.00 D8080* , Rep laces 22009, Z2OL1-, and 22072. Limited to one per lifetime. $775.00
Minor Treatment to Control Harmful Habits D82rO* See separate table for associated remarks field code. See separate table * = Selices payable to an FQHC for a cl¡ent encountet
CDT only copyright 2008 Amercan Denta Association All righls reserued t94t Section 19
ProcedureGode Limitations Maximum Fee D8220* See separate table for associated remarks field code. See separate table Other Orthodont¡c D8660* Replaces Z2QO8. Denied when bill on the same DOS as D0145. $15.00 Replaces Z2OL3 $68.10 Replaces Z2OI4 and Z2OI5; one retainer per arch per lifetime; $100.00 may be replaced once because of loss or breakage (prior authori- zation is required) D8690* Bracket replacement. $20.00 D8691 Not considered medically necessary NC D8693 $50.00 D8999 Manually priced * = Services payable to an FQHC for a client encounter
L9.2O Special Orthodontic Appliances As with all otthodontic services, all removable or fixed special orthodontic applicances must be prior authorized. The prior authorization request must include both the national code and remarks code. However, prior authorizat¡on requests may omit the DPC prefix to the eight¡igit remarks code. All removable orfixed special orthodontic appliances must be billed with national procedure code DA21O or D822O. Dental models must be submitted when requesting prior authorization of a thumb- sucking ortongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific service is also required. The appropriate remarks codes must be entered on the authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enter the DPC remarks code and the appropriate procedure code will not result in claim denial; however, manual intervention is required to process the claim, which may result ¡n a delay of payment. For paper claim submissions, providers must enterthe local procedure code in Block 35 (Remarks) of the 2006 ADA claim form. For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure correct a uthorization, accu rate records, a nd re i m bu rsement. For electronic submissions other than TexMedConnect submissions, providers must follow the steps below to ensure TMHP accurately applies the correct local procedure code to the appropriate claim detail: 1) The DPC prefix must be submitted, only once, in the firstthree bytes of the NTE02 atthe 2400 loop. 2) ln bytes 4-8, providers must submit the remark code (local procedure code) based on the order of the claim detail. Do not enter any spaces or punctuat¡on between remark codes, unless to designate the detail is not billed with D8210 or D822O. Example: For a claÌm with three details, where details one and three are subm¡tted with procedure code D8210 and detail two ¡s not, enter the following information in the NTE02 at the 2400 loop: DPC| 01 4D 1046D. (The space shows that detail two needs no local code.) lf all details require a local code, enter DPC, no spaces, and the appropriate local codes, To submit using TexMedConnect, providers must enter the local code into the Remarks Code field, located underthe details header. The Remarks Code field is the field directly afterthe Procedure Code field. TexMedConnect submitters are not required to manually enter the DPC prefix as it is placed in the appropriate field on the TexMedConnect electronic claim.
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L9.2L How to Score the Handicapping Labio-lingual Deviation (HLD) lndex The orthodontic provider must complete and sign the diagnosis (Angle class). Cleft Palate Submit a cleft palate case in the mixed dentition only if it can be justified in a narrative why there should be treatment before the client is in the full dentition. Note: lntermittent treatment requests may exceed the allowable 26 reimbursable treatment visits. Severe Traumatic Deviations Refers to facial accidents only. Po¡nts cannot be awarded for congenital deformity. Severe traumatic deviations do not include traumatic occlusions for crossbites. Overjet in Millimeters Score the case exactly as measured, then subtract 2 mm (considered the norm), and enterthe difference as the score. Overbite in Millimeters Score the case exactly as measured, then subtract 3 mm (considered the norm), and enter the difference as the score. This would be doublecounting. Mandibular Protrusion in Millimeters Score the case by measurement in mm bythe distance from the labial surface of the mandibular incisors to the labial surface of the maxillary incisor. Do not score both overbite and open bite. Open Bite in Millimeters Score the case exactly as measured. Measurement should be recorded from the line of occlusion of the permanent teeth, not from ectopically erupted teeth in the anterior segment. Caution is advised in undertaking treatment of open bites in older teenagers, because of the frequency of relapse. Ectopic Eruption An unusual pattern of eruption, such as high labial cuspids orteeththataregrosslyoutof the longaxis of the alveolar ridge. Do not include (score) teeth from an arch if that arch is to be counted in the following category of Anterior Crowding. For each arch, either the ectopic eruption or anterior crowding may be scored, but not both. Anterior Crowding Anterior teeth that require extractions as a prerequisite to gain adequate room to treat the case. lf the arch expansion is to be implemented as an alternative to extraction, provide an estimated number of appointments required to attain adequate stabilization. Arch length insufficiency must exceed 3.5 mm to score for crowding on any arch. Mild rotations that may react favorably to stripping or moderate expansion procedures are not to be scored as crowded. Labio-lingual Spread in millimeters The score forthis category should be the total, in millimeters, of the anterior spaces. Providers should be conservative in scoring. Liberal scoring will not be helpful in the evaluation and approval of the case. The case must be considered dysfunctional and have a minimum of 26 points on the HLD index to qualify for any orthodontic care other than crossb¡te correction. Half-mouth cases cannot be approved. The intent of the program is to provide orthodontic care to cl¡ents with handicapping malocclusion to improve function. Although aesthetics is an important part of self-esteem, services that are primarily for aesthetics are not within the scope of benefits of this program. The proposals for treatment services should incorporate only the minimal number of appliances required to properlytreatthe case. Requests for multiple appliances to treat an individual arch will be reviewed for duplication of purpose. lf attaininga qualifyingscore of 26 points is uncertain, providers should include a brief narrative when submittingthe case. The narrative may reduce the time necessaryto gain final approval and reduce shipping costs incurred to resubm¡t records. Providers must properly label and protect all records (especially plaster diagnostic models) when shipping. lf plaster diagnostic models are requested by and shipped to TMHP, the provider should assure that the models are adequately protected from breakage during shipping. TMHP will return intact models to the prov¡der.
CD-f only copyright 2008 Ameícan Dental Associataon. All rights reseryed 19-45 Section 19
L9.2L.L HLD Score Sheet This sheet and a Boley Gauge are required to score. Procedure: . Occlude client or models in centric position. . Record all measurements rounded-off to the nearest millimeter. . Enter a score of 0 if the condition is absent. . Overjet is measured from the most protrusive inc¡sor. . Overbite is measured from the labio-incisal edge of overlapped anterior tooth or teeth to point of maximum coverage. . Ectopic eruption and anterior crowding: Do not double-score. Record the more serious condition.
PLEASE PRINT CLEARLY:
Client Name: Date of birth Medicaid lD:
Address: (Street/City/County/State/Zip Code)
CONDITIONS OBSERVED HLD SCORE Cleft Palate Score 15
Severe Traumatic Deviations Score 15 Trauma/Accident related only Overjet in mm. Minus 2 mm. Example: I mm. - 2 mm. = 6 points Overbite in mm. Minus 3 mm. Example: 5 mm. - 3 mm. = 2 points Mandibular Protrusion in mm. x5 See definitions/instructions to score (previous page) Open Bite in mm. x4 See definitions/instructions to score (previous page) Ectopic Eruption (Anteriors Only) Each tooth x3 Reminder: Points cannot be awarded on the same arch for Ectopic Eruptíon and Crowding Anterior Crowding Max. Mand = 5 pts. each 1O point maximum total for both arches arch combined Labio-lingual Spread in mm TOTAL Diagnosis For TMHP use only Authorizat¡on Number
Examiner: ,Recorder: Provider's Signature
Please submit this score sheet with records
19-46 CDI only copyr¡ght 2008 American Dental Associatron All ri8hts reserued Appendix G Dear Manual User: Welcome to the 2OO8 Texas Medicaid Provider Procedures Manual. To enhance usability, this manual is available on a searchable CD-ROM and on the TMHP website at www.tmhp.com. Note: Atl users who access www.tmhp.com are required to accept the American Medical Association (AMA) End-user Agreement on the use of Current ProceduralTerminology (CPT). For each computer that accesses the TMHP website, the agreement must be accepted every 30 days from the last date on which the agreement was accepted by the user. lf the end-user agreement is not accepted on a par-ticular computer every 30 days, no user will be able to enter the website from that computer. For add¡t¡onal information about the AMA and CPT, refer to www.ama'assn.org/ama/pub/category /31-73.html. A C/aims FitinS Resourcestable is located at the end of each service section with page references to all claim instructions, appendices, Medicaid forms, and claim form examples associated with the service. This manual contains both the Primary Care Case Management (PCCM) and Texas Health Steps (THSteps) manuals. PCCM information can befound primarily in Section 7, though relevant informatlon can be found in other sections. THSteps information is contained in Section 43 and throughout the manual. The Texas Medicaid Program policy published in this manual represents policy implemented as of October 31,,2OO7. Policy updates effective after October 3L,2OO7, are published bimonthly in the Texas Medicaìd Bu lletin. The November/December 2OO7 Texas Medicaid Bulletin and all Texas Medicaîd Bulletins through and including the September/October 2008 lexas Medicaid Bulletin supplement the 2008 Texas Medicaid Provider Procedures Manual and update the policy contained herein' The fexas Medicaid Provider Procedures Manual serves as a comprehensive guide for Texas Medicaid providers, and contains information aboutTexas Medicaid benefits, policies, and procedures. The manual also includes an overyiew of the State of Texas Medicaid lvlanaged Care programs to include the State of Texas Access Reform (STAR), STAR+PLUS, PCCM, and NorthSTAR. The information regardingthe State of Texas Medicaid Managed Care programs, including Section 7, is not an exhaustive policies ancl procedures guide. For specific managed care informat¡on, contact the individual heatth plans participating in STAR, STAR+PLUS, and NorthSTAR. For PCCM, refer to the TMHP Telephone and Address Guide included in this manual.
Provider Manual Overview The 2OO8 Texas Medicaid Provider Procedures Manual is divided into three parts, including
Part l: Provider lnformation The information in Part I is for all health-care providers who are enrolled in the Texas Medicaid Program and provide services to Texas Medicaid clients. ln Part l, providers find instructions for providing allowable services and receiving appropriate reimbursement for services. The following sections are included in Part l: . lntroduction. . TlvlHP Telephone and Address Guide. . Section 1. Provider Enrollment and Responsibìlitres. . Sect¡on 2. Texas lvledicaid Reimbursement. . Section 3. TMHP Electronic Data lnterchange (EDl). . Section 4. Client EligibilitY. . Sect¡on 5. Claims Filing. . Section 6. Appeals. . Section 7. Mana1ed Care.
Part ll: Texas Medicaid Services Part ll contains a section for each Texas Medicaid service with information on health-care policy, proce- dures, and claims filing pertaining to each provider type.
CPT only copyíght 2OO7 Ar¡eilca¡ lvledlcal All rlghts reserued ^ssocratron Section 1
documents or other requested items may be altered or 1,.2.4 Release of Gonfidential lnformation destroyed, the reguest must be completed by the prov¡der lnformation about the diagnosis, evaluat¡on, or treatment at the t¡me of the request or in less than 24 hours as of a client with Texas Medicaid Program coverage by a provided by the requestor. lf , in the opinion of the lnspector person licensed or certified to peform the diagnosis, General or other requestor, the requested documents and evaluation, or treatment of any medical, mental, or other items requested cannot be completely provided on emotional disorder, or drug abuse, is confidential infor- the day of the request, the ,nspector General or requestor mation that the provider may disclose only to authorized may set the deadline for production at 24 hours from the people. Family planning information is sensitive, and t¡me of the orig¡nal reguest. confidentiality must be ensured for all clients, especially Failure to supply the reguested doc uments and other items, mtnors. w¡thin the time frame specified, may result in payment hold Only the client may give written permission for release of to the provider's Medicaid payments, recoupment of any pertinent information before client information can be payments for all claims related to the miss¡ng records, released, and confidentiality must be maintained in all contract cancellation, and/or exclusion from the Texas other respects. lf a client's medical records are requested Medicaíd Progiram. by a licensed Texas health-care provider or a physician As directed by the requestor, the provider or person will licensed by any state, territory, or insular possession of relinquish custody of the requested documents and other the United States or any State or province of Canada, for Items and the requestor will take custody of the records purposes of emergency or acute medical care, a provider and remove them from the premises. lf the requestor must furnish such records at no cost to the requesting should allow longer than "at the time of the request" to provider. This includes records received from another produce the records, the provider will be required to physician or health{are provider involved in the care or produce all records completed, at the time of the treatment of the patient. lf the records are requested for completion or at the end of each day of production, as purposes other than for emergency or acute medical care, directed by the requestor who will take custody of the the provider may charge the requesting provider a requested items. reasonable fee and retain the requested information until payment is received. lf the provider places the required information in another legal entity's records, such as a hospital, the provider is The client's signature is not required on the claim form for responsible for obtaining a copy of these requested payment of a claim, but HHSC recommends the provider records for use by the requesting state and federal obtain written authorization from the client before agencies. releasing confidential medical information. A release may be obtained by having the client s¡gn the indicated block These documents and claims must be retained for a on the claim form after the client has read the statement minimum period of five years from the date of service or of release of information that is printed on the back of the until all audit quest¡ons, appeal hearings, investigations, or court cases are resolved. Freestanding RHCs must form. The client's authorization for release of such infor- retain their records for a minimum of six years, and mation is not required when the release is requested by and made to DADS, HHSC, DSHS, TMHP, DFPS, DARS, hospital-based RHCs must retain their records for a HHSC OlG, the Texas Attorney General's MFCU or m¡nimum of ten years. These records must be made available immediately at the time of the request to Antitrust and Civil Fraud Division, or HHS. employees, agents, or contractors of HHSC Offìce of lnspector General (OlG), the Texas Attorney General's Medicaid Fraud Control Unit (MFCU) or Antitrust and Civil L.2.5 Compliance w¡th Federal Legislation Medicaid Fraud Section, TMHP, DFPS, the Department of HHSC complies with HHS regulations that protect against Aging and Disability Services (DADS), Department of State discrimination. All contractors must agree to comply with Health Services (DSHS), Department of Assistive and the following: Rehabilitative Services (DARS), U.S. Department of Health . Tiile Vl of the civil Ri$hts Act of 7964 (Public Law and Human Services (HHS) representative, any state or 88-352), Section 504 of the Rehabilitat¡on Act of 7973 federal agency authorized to conduct compliance, (Public Law 93-112), The Americans with Disabilities Act regulatory, or program integrity functions on the provider, of 7990 (Public Law 101-336), T¡tle 40, Chapter 73, of person, or the services rendered by the provider or the TAC, all amendments to each, and all requirements person, or any agent, contractor, or consultant of any imposed by the regulations issued pursuant to these agency or division delineated above. ln addition, the acts. The laws provide ¡n part that no persons in the provider must meet all requirements of 1 TAC, Part 15, U.S. shall, on the grounds of race, color, national or¡gin, s371.1643(f). age, sex, disability, political beliefs, or rel¡gion, be The records must be available as requested by each of excluded from participation in or denied any aid, care, these entities, during any investigation or study of the service, or other benefits provided by federal and/or appropriateness of the Medicaid claims submitted by the state funding, or otherwise be subjected to any provider. discrimination.
1-8 cPl only copyright 2007 Amer¡can Medical Association All rights reseryed Provider Enrollment and Responsibil¡ties
. Health and Safety Code 85.773 as described in "Model be directed to communicate with the provider to offer Workplace Guidelines for Businesses, State Agencies, assistance with the techn¡cal or administrative aspects of and State Contractors" on page G-2 (relating to the Texas Medicaid Program. workplace and confidentiality guidel¡nes on AIDS and At the direction of the HHSC OlG, a provider's claims may Hrv). be manually reviewed before payment. Parameters are Exception: ln the case of minors receiving family planning developed for prepayment review based on the specific services, onlythe cl¡ent may consentto release of medical areas of concern identified in each case. As part of the documentation and information. Providers must comply prepayment review process, providers are required to with the laws and regulat¡ons concerning discrimination. submit paper claims, rather than electronic claims, along Payments for services and supplies are not authorìzed with supporting medical record documentation (e.9., unless the services and supplies are provided without clinical notes, progress notes, diagnost¡c testing results, discrimination on the basis of race, color, sex, nat¡onal other reports, superbills, X-rays, and any related medical or¡g,¡n, age, or disability. Send written complaints of record documentation) attached to each claim for all noncompliance to the following address: services billed. This documentation is used to ascerta¡n that the services billed were medically necessary, billed HHSC Commissioner appropriately, and according to Texas Medicaid Program 11OO West 49th Street requirements and policies. Services inconsistent with Austin, ÍX78756-3]-72 Texas Medicaid Program requirements and policies are Reminder: Each provider must furnish covered Medicald adjudicated accordingly. C la ims su bm itted initial ly without services to eligible clients in the same manner, to the same the supporting medical record documentation will be extent, and of the same quality as services provided to denied. Additional medical record documentation other pat¡ents. Services made available to other patients submitted by the provider for claims denied as a result of rnust be made available to lexas Medlcaid clients if the the prepayment review process is not considered at a services are benefits of the Texas Medicaid Proglram. later time. A provider is removed from prepayment review only when determined appropriate by the HHSC OlG. Once removed from prepayment review, a follow-up assessment 1,.2.6 Utilization Control General ofthe provider's subsequent practice patterns is Provisions - performed to monitor and ensure continued appropriate T¡tle XIX of the Social Security Act, Sections 1902 and use of resources. Noncompliant providers are subject to 1903, mandates utilization control of all Texas Medicaid administrative sanctions up to and includ¡ng exclusion Program services under regulations found at Title 42 CFR, and contract cancellation, as deemed appropriate by the Part 456. Utilization review activities required by the Texas HHSC OIG as defined in the rules in 1 TAC 9371.1643. Medicaid Program are completed through a series of Providers placed on prepayment review must submit all paper claims and supporting medical record documen- monitoring systems developed to ensure the quality of services provided, and that all services are both medically tation to the following address: necessary and billed appropriately. Both clients and Texas Medicaid & Healthcare Partnership providers are subject to utilization review monitor¡ng. Utili- Attention: Prepayment Review MC-411 SURS zation control procedures safeguard against the delivery PO Box 203638 of unnecessary seruices, monitor quality, and ensure Austin, Texas 78720-3638 payments are appropriate and according to Texas Medicaid Program policies, rules, and regulations. All providers identified as a result of utilization control activ- 1-.2.7 Provider Gertification/Ass¡gnment ities are presented to HHSC OIG to determine any and all Texas Medicaid service providers are required to certify subsequent actions. compliance with or agree to various provisions of state The primary goal of utilization control activity is to identify and federal laws and regulations. After submitting a providers with practice patterns inconsistent with the signed claim to TMHP, the provider certifies the follow¡ng: federal requirements and the Texas Medicaid Program . Services were personally rendered by lhe billing scope of benefits, policies, and procedures. The use of provider or under the personal supervision of the billing utilization control monitoring systems allows for identifi- provider, if allowed for that provider type, or under the cation of providers whose patterns of practice and use of substitute physician arrangement. services fall outside of the norm for their peer groups. Providers identified as exceptional are subject to an in- . The information on the claim form is true, accurate, and depth review of all Texas Medicaid billings. These review complete. findings are presented to the HHSC OIG to determine any . All services, supplies, or items billed were medically necessary action. Medical records may be requested from necessary for the client's diagnosis or treatment. the provider to substantiate the medical necessity and Exception is allowed for special preventive and appropriateness of services billed to the Texas Medicaid screening programs (for example, family planning and Program. lnappropriate service utilization may result in Texas Health Steps [THSteps]). recoupment of overpayments and/or sanctions, or other : Medical records document all services billed and the administrative actions deemed appropriate by the HHSC medical necessity of those services. OlG. There are instances when a tra¡ning specialist may
CPT only copyright 2OO7 American lvedical Assæ¡ation All r¡ghts reseryed 1-9 Section 19
with gross malocclusion that will benefit from early L9.L7 Hospitalization and ASG/HASC treatment. Cleft palate cases do not have to meetthe HLD Dental services performed in an ASC, hospital ambulatory 26-po¡nt scoring requirement. However, ¡t is necessary to surgical center (HASC), or a hospital (either as an submit a sufficient narrative and/or outline of the inpatient or an outpatient) may be benefits of THSteps on proposed treatment plan when requesting author¡zat¡on the medical or behavioral justification provided, or if one for orthodontic services on cleft palate cases. of the following conditions exist: . The procedures cannot be performed in the dental . Crossþite therapy.
office. . Head injury involving severe traumatic deviation. . The client is severely disabled. The following limitations apply for orthodontic services:
Contact the individual HMO for precertification require- . Orthodontic services for cosmetic purposes only are ments related to the hospital procedure. lf services are not a benefit of the Texas Medicaid Program or precertified, the provider receives a precertification THSteps. number effective for 90 days. . Orthognathic surgery, to include extractions, required or ln those areas of the state with Medicaid Managed Care, provided in conjunction with the application of braces precertification or approval is required from the client's must þe completed while the client is Medicaid-eligible HMO for anesthesia and facility charges. lt is the dental in order for reimbursement to be considered. provider's responsibility to obtain precertification from the . Except for D8660, all orthodontic procedures require client's HMO or managed care plan for facility and $eneral prior authorization for consideration of reimbursement. anesthesia services. . The THSteps client must be Medicaid/THSteps-eligible To be reimbursed by the HMO, the provider must use the when authorization is requested and the orthodontic HMO's contracted facility and anesthesia provider. These treatment plan is initiated. lt is the provider's responsi- services are included in the capitation rates paid to bility to see that the client has a current Medicaid H MOs, and the faci ity,/anesthesiologist risk nonpayment I ldentification Form (Form H3087) or Medicaid Eligibility from the HMO without such approval. Coordination of all Verification Form (Forms HtO27 and HLO27-A-C) and specialty care is the responsibility of the client's primary that the date of birth on the form indicates the client is care provider. The primary care provider must be notified younger ùhan 2L years of age and no limitations are by the dentisl and/ or the HMO of the planned seruices. indicated. Dentists providing sedation/anesthesia services must . Prior authorization is issued to the requesting provider have the appropriate current permit from the TSBDE for only and is not transferable to another provider. lf the the level of sedation/anesthesia provided. client changes providers or if the provider stops The dental provider must be in compliance w¡th the guide- practicing dentistry in the Texas Medicaid Program for lines detailed in "Criteria for Dental Therapy Under whatever reason, a new prior authorization must be General Anesthesia" on page 19-33. requested (see "Transfer of Orthodontic Services" on page 19-38). Note: Post-treatment authorization will not be approved for codes that require mandatory prior authorization. The following procedure codes, policies, and limitations are applied to the processing and payment of orthodontic services under THSteps dental services: 19.18 Orthodontic Services . Procedure code D8660 is allowed when: (THSteps) . The client is referred to an orthodontist for a determi- nation of whether orthodont¡c services are indicated Orthodontic services for cosmetic purposes only are not a and to determine the appropriate time to initiate benefit of the Texas Medicaid Program. Orthodontic such services. seryices are limited to the treatment of severe handi- capping malocclusion and other special medically . The client is referred to an orthodontist and elects to necessary circumstances as outlined in Benefits and receive services from another orthodontic provider Limitations below. because of justifiable reasons. . Repeat visits at different age levels are requlred to determine the appropriate time to initiate 19.18.1 Benefits and Limitations orthodontic treatme nt. Orthodontic services include the following: . Procedure code D8680 is payable for one retainer per . Correction of severe handicapping malocclusion as arch, per lifetime, and may be replaced once because measured on the Handicapping Labiolingual Deviation of loss or breakage (prior authorization is required). (HLD) lndex. Refer to page L9-42 for information on . Procedure code D8670 should be billed only when an how to score the HLD. A minimum score of 26 points is adjustment to the appliances is provided and may not required for full banding approval (only permanent be billed before the date the orthodontic adjustment dentition cases are considered). was performed. The number of visits for monthly adjust- Exception: Retained deciduous teeth and cleft palates ments to the appliances is restricted to the number
19-36 CPT only copyright 2o07 Amencan l\¡edical Assocration All rights reserued Dental
that was authorized ¡n the treatment plan. However, the lf orthodontic treatment is medically indicated, providers number of monthly visits may be amended with appro- are responsible for obtaining prior authorization for a priate documentation of medical necessity while the complete orthodontic treatment plan while the client is client is Medicaid eligible. eligible for Medicaid and THSteps and younger Than 21- . years of age. Procedure code D867O is paid only in conjunction with a history of braces (code D8080), unless special Prior authorization is a condition for reimbursement; ¡t is circumstances exist. not a guarantee of payment. . All orthodontic codes and appliances are global fees. Upon receipt of prior authorization of complete treatment . plans, provlders are to adv¡se clients that they will be able Separate fees for adjustments to retainers are not payable. to receive the approved treatment services (e.9. orthodontic adjustments, bracket replacements and . The appropriate code should be billed for those appli- retainers), even if they lose Medicaid eligibility or reach ances required as part of the treatment of cleft palate 2t years of age. Approved ofthodontic treatment must be cases. initiated before the loss of Medicaid eligibility and Special orthodontic appliances may also þe used with full completed within 36 months of the authorization date. banding and crossbite therapy w¡th approval by the TMHP Note: Providers must submit all orthodontic seruices for Dental Director. Medicaid Managed Care cl¡ents follow¡ng, these guide- . Procedure codes D5951, D5952, D5953, D5954, lines. STAR and STAR+PLUS are not responsible for D5955, D5958, D5959, and D5960 are to be used as orthodontic services. applicable with documentation of medical necessity. Requests for orthodontic services must be accompanied Otherwise, use the appropriate special orthodontic by all the following documentation: appliance code. . An orthodontic treatment plan. The treatment plan . Full banding is allowed on permanent dentltion only, must include all procedures required to complete full and treatment should be accomplished in one stage treatment (such as, extractions, orthognathic surgery, and is allowed once per lifetime. upper and lower appliance, monthly adjustments, antic- Exception: Cases of mixed dentition when the treatment ipated bracket replacements, appliance removal if plan includes extract¡ons of remaining primary teeth or indicated, spec¡al orthodontic appliances, etc.). The cleft palate. treatment plan should incorporate only the minimal number of appliances required to properly treat the . Crossbite therapy is allowed for primary, mixed, or case. Requests for multiple appliances to treat an permanent dentition. individual arch are reviewed for duplication of purpose. . Providers must not requestcrossbite correctlon (limited . Cephalometric radiograph with tracing models orthodontics) for a mixed dentition client when there is a need for full banding in the adult teeth. Crossbite . Completed and scored HLD sheet with diagnosis of therapy is an inclusive charge for treating the crossbite Angle class (26 points required for approval of non-cleft to completion, and additional reimbursement is not palate cases). provided for adjustments or ma¡ntenance. . Facial photographs. . lf a case is not approved, the dentist may file a claim . Full series of radiographs or a panoramic radiograph; for payment of the diagnostic work-up necessary to diagnostic-quality films are required (copies are obtain the authorization using procedure codes D0330, accepted and radiographs will not be returned to the D0340, D0350, and D0470. The dentist may receive provider). payment under these procedure codes for no more than . Any additional pertinent information as determined by two cases out of every ten cases denied. The dent¡st the dentist or requested by TMHP's Dental Director should determine if the client's condition meets Requests for crossbite therapy require properly orthodontic benefit criteria before performing a trimmed models to be retained in the office and must diagnostic work-up. demonstrate the following criteria: . Procedure codes D8080, D8050, and D8060, are . Posterior teeth. Not end to end, but buccal cusp of limited to one per lifetime. upperteeth should be lingual to buccal cusp oflower teeth. L9.L8.2 Mandatory Prior Authorizat¡on . Anter¡or teeth. The incisal edge of upper should be lingual to the incisal of the opposing arch. Prior authorization is required for all THSteps orthodontic services except for procedure code D8660. The prior The dentist should be certain that radiographs, photo- authorization request must contain the date of service graphs, and other information are properly packaged to thatthe orthodontic records were produced. lf the request avoid damage. TMHP is not responsible for lost or is approved, the date that the records were produced is damaged materials. considered to be the date on which orthodontic treatment beg¡ns.
CPT only copyr¡ght 2007 Amer¡can Medical Assæ¡aliø All rights reseryed L9-37 Section 19
19.18.3 Gompletion of Treatment Plan sheet, nor does the client have to meet the HLD lndex of 26 points. However, a complete plan of treatment ¡s lf a client reaches 2tyears of age or loses Medicaid eligi- required. bility before the authorized orthodont¡c treatment is completed, reimbursement is provided to complete the Note: Medicaid clients who initiate orthodontic services orthodontic treatment that was authorized and initiated privately (e.g. pay out of pocket for the orthodont¡c workup whi le the cl ient was younger tha n 2t years of age, el¡gible and,/or initial band¡ng, etc.) while Medicaid eligible due to for Medicaid and THSteps, and completed within not meet¡ng the HLD index 26-points, are not eligible to 36 months. Any orthodontic-related service requested have their orthodontic services transferred to and (e.g., extractions or surgeries) must be completed before reimbursed by Medicaid. the loss of client eligibility. Services cannot be added or To request prior authorization to complete the orthodontic approved after Medicaid/THSteps eligibility has expired. treatment initiated by another provider, complete a THSteps Dental Mandatory Prior Authorization Request Form and send it with the complete plan of treatment and L9.L8.4 Premature Removal of Appliances appropriate documentation for orthodontic seryices The overall fee for orthodontic treatment (D8080) and/or crossbite therapy to the TMHP Dental Director at includes the removal of orthodontic brackets and/or the following address: treatment appliances. Procedure code D7997 may be Texas Medicaid & Healthcare Partnership used only when the appliances were placed by a different THSteps and ICF-MR Dental Authorization and lnformation provider with an unaffiliated practice (not a partner or PO Box 2O29t7 office-sharing arrangement) and one of the following Austin, ÎX 74720-29]-7 conditions exist: . There is documentation of a lack of cooperation from the client. 19.18.6 Comprehens¡ve Orthodontic . The client requests premature removal and a release Treatment form has been signed by the parent, Suardian, or client Comprehensive orthodontic services (procedure code if he is at least 18 years of age. D8080) are restricted to cl¡ents who are 12 years of age Providers must keep a copy of the release form on file and and older or clients who have exfoliated all primary are responsible for this documentation during a review dentition. process. National procedure codes do not allow for any work-in- progress or partial billing by separating the three orthodontic components: diagnostic work-up, orthodontic 19.18.5 Transfer of Orthodontic Services appliance (upper), or orthodontic appliance (lower). Prior authorization issued to a dental provider for When b¡ll¡ng for comprehensive orthodontic treatment, orthodontic services is not transferable to another dental D8080, three local codes must be submitted as remarks provider. The new provider must submit to TMHP a new codes along with code D8080. Local codes (Z2OO9, prior authorization request ¡n order to be approved to Dia gnostic work-u p a p proved, Z2O L1-, O rthodontic complete the orthodontic treatment initiated by the appliance, upper, or 22012, Orthodontic appliance, lower) original provider. are placed in the Remarks Code field on electronic claims The following supporting documentation must accompany or Block 35 on paper claims. the new request for orthodontia services and must include Note: lf the remarks code and procedure code D8O8O are the date of service the orthodontic records were not submitted, the claÌm will be denied. produced: Each remarks code pays the correct reimbursement rate . All of the documentation as required for the original which, when combined, totals the maximum payment of provider. $775. D8080 must be billed on three separate details, . The reason the client left the previous provider, if with the appropriate remarks code, even if billing for the known. work-up and full band¡ng. Billing only one detail for a total of $775 will not be accepted. . An explanation of the treatment status. Example 1: A client is approved for full banding, but after . A compete treatment plan addressing all procedures for the initial work-up, the client discontinues treatment. This which authorization is being requested (such as the provider would bill the national code D8080 and place the number of monthly adjustments or retainers required to local code Z2OO9, D¡agnostic work-up approved, in the complete the case). Remarks,/comment field. The claim would pay $175. . A full diagnostic work-up (D8080) with an HLD lndex. Example 2: A client is approved for full banding. The The score of 26 points will be modified according to any provider continues treatment and places the maxillary progress achieved. bands. The provider would bill the national procedure code Exception:'The prior authorization requests for clients D8080 and place the local code 72OO9, Diagnostic work- who ¡nitiate orthodontic services before becoming el¡g¡ble up approved, and Z2OII, Maxillary bands, in the for Medicaid do not require models or the HLD score Remarks,/comment field. The claim would pay $475.
19-38 CPT only copyright 2007 American Medical Assocjation A¡l rights reseryed Dental
All electronic claims for D8080 must have the appropriate remarks code associated with the procedure code. Providers should adhere to the following guidelines for electronic claim submission so that TMHP can accurately apply the correct remarks code to the appropriate claim detail. A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, ¡n the first three bytes ofthe NTE02 at the 2400 loop. Example L= For a claim with one detail, submitted with procedure code D8080 and remarks code Z2OO9, enterthe information as follows: DPCZ2009. The total billed would be $175. Exampfe 2z For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are Z2OO9 and Z2OII, enter the information as follows: DPCZ2OO9Z2011. The total billed would be $475. Example 3: For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code þased on the order of the claim detail as follows: DPC220092201,122072. The total billed would be $775. This method ensures accurate and appropriate payment for services rendered and addresses the need for paftial billing.
L9.L8.7 Orthodontic Procedure Codes and Fee Schedule When submitting claims for orthodontic procedures, use the following procedure codes Procedure Code Limitations Maximum Fee Orthodontic Services D0330*, When requested orthodontic cases are submitted for authorization $100.00 D0340*, and denied, two out of ten denials will be paid. These four DO350x, and procedure codes, when billed together for denied cases, replace D0470* local procedure code Z2OLO. D7280 A1_-20 $62.50 D7997* Replaces Z2OL6. Not payable to the dentist who placed the $50.00 appliance. lncludes removal of arch bar and premature removal of braces. A1--20
D8050* Replaces Z2Ot8 and 8110D. Limited to one per lifetime. $340.00 D8060* Replaces Z2OLa and 8120D. Limited to one per lifetime. $340.00 D8080* Replaces Z2OO9, Z2O1-!, and Z2Qt2. Limited to one per lifetime $775.00
Minor Treatment to Control Harmful Habits D8210* See separate taþle for associated remarks field code See separate table D8220* See separate table for associated remarks field code See separate table
D8660* Replaces Z2OO8. $15.00 D8670* Replaces Z2OI3 $68.10 D8680* Replaces Z2OI4 and 22075. $100.00 D8690* Bracket replacement. $20.00 D8691 Not considered medically necessary NC
D8692 Limited to one service per arch per lifetime for each retainer NC
D8999 Manually priced * = Services payable to an FQHC for a client encounter
CP-f only copyr¡ght 2007 American Med¡cal Assæ¡at¡on All rights reseryed 19-39 Section 19
19.19 Special Orthodontic Appliances As with all orthodontic services, all removable or fixed special orthodontic applicances must be prior authorized. The prior authorization request must include both the national code and remarks code. However, prior authorization requests may omit the DPC prefix to the e¡ght-digit remarks code. All removable or fixed special orthodontic appliances must be billed with national procedure code D82\O or D822O. Dental models must be submitted when requesting prior authorization of a thumb- sucking or tongue thrust appliance. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific seruice is also required. The appropriate remarks codes must be entered on the authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enterthe DPC remarks code and the appropriate procedure code will not result in claim denial; however, manual intervention is required to process the claim, which may result in a delay of payment. For paper claim submissions, providers must enter the local procedure code in Block 35 (Remarks) of the 2006 ADA claim form. For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure correct authorization, accurate records, and reimbursement. For electronic submissions other than TexMedConnect or TDHconnect software submissions, providers must follow the steps below to ensure TMHP accurately applies the correct local procedure code to the appropriate claim detail: t) The DPC prefix must be submitted, only once, in the first three bytes of the NTEO2 at the 2400 loop. 2) ln bytes 4-8, providers must submit the remark code (local procedure code) based on the order of the claim detail. Do not enter any spaces or punctuat¡on between remark codes, unless to designate the detail is not billed with D8210 or D822O. Example: For a claim w¡th three details, where details one and three are submitted wìth procedure code D8270 and detail two rs not, enter the followin! information ¡n the NTE02 at the 24OO loop: DPC7074D 7046D. (The space shows that detail two needs no local code.) lf all details require a local code, enter DPC, no spaces, and the appropriate local codes. To submit using TexMedconnect or TDHconnect software, providers must enter the local code into the Remarks Code field, located underthe details header. The Remarks Code field is the field directly after the Procedure Code field. TexMedConnect and TDHconnect software submitters are not required to manually enter the DPC prefix as it is placed in the appropriate field on the TexMedConnect or TDHconnect electronic claim. The following table identifies the appropriate DPC remarks codes to use when requesting authorization or billing for procedure code D8210 or D822O: Procedure Remarks Maximum Code Gode Remarks Code Desctiption Fee Special Orthodontic Appliances D8220* DPC1000D Appliance with horizontal projections $250 D8220* DPC1001D Appliance with recurved springs $250 D8220" DPClOO2D Arch wires for crossbite correction (for total treatment) $595 D8220* DPC1003D Banded maxillary expansion appliance $375 D8270* DPC1004D Bite plate/bite plane $100 D8210* DPC1005D Bionator $1oo D8210* DPC1006D Bite block $250 D82LO* DPC1007D Bite-plate with push springs $250 D8220* DPC1008D Bonded expansion device $225 D82LO* DPC1010D Chateau appliance (face mask, palatal exp and hawley) $300 D82tO* DPC1011D Coffin spring appliance $275 D8220* DPCLOL2D Crib $10o * = Services payable to an FQHC for a client encounter
19-40 cPT only copyright 2007 Amer¡can ¡.4edical Assoc¡at¡on All r¡ghts reseryed Dental
Procedure Remarks Maximum Code Code Remarks Gode Description Fee D8210* DPC1O13D Dental obturator, definitive (obturator) $250 D8210* DPC1O14D Dental obturator, surg¡cal (obturator, surgical stayplate, $250 immediate tem porary obturator) D8220'É DPC1015D Dista lizing appliance with springs $250 D8220'( DPC1016D Expansion device $375 D8210* DPC1017D Face mask (protraction mask) $350 D8220* DPC1O18D Fixed expansion appliance $375 D8220* DPC1019D Fixed lingual arch $225 D8220* DPC1020D Fixed mandibular holding arch $100 D8220" DPCLO2AD Fixed rapid palatal expander $375 D82LO* DPCtO22D Frankel appliance $100 D8210* DPC1023D Functional appliance for reduction of anterior openbite and $375 crossbite D82aO* DPC7024D Headgear (face bow) $150 D8220" DPC1025D Herbst appliance (fixed or removable) $250 D8220* DPC1026D lnter-occlusal cast cap surgical splints $375 D8210* DPC].O2TD lntrusion arch $100 D8220* DPC1028D Jasper jumpers $100 D8220* DPC1029D Lingual appliance with hooks $100 D8220* DPC1030D Mandibular anterior bridge $175 D8220+ DPC1031D Mandibular bihelix (similar to a quad helix for mandibular $10o expansion to attempt nonextraction treatment) D8210* DPC1032D Mandibular lip bumper $100 D8220" DPC1O36D Mandibular lingual 6x6 arch wire $100 D82rO* DPC1037D Mandibular removable expander with bite plane (crozat) $275 D82tO+ DPC1038D Mandibular ricketts rest posit¡on splint $375 D8210* DPC1039D Mandibular splint $225 D8210* DPClO4OD Maxillary anterior bridge $175 D8210* DPC1041D Maxillary bite-opening appliance w¡th anterior springs $100 D8220" DPCLO42D Maxillary l¡ngual arch with spurs $1oo D8220" DPC1O43D Maxillary and mandibular distalizing appliance $1oo D822O'r DPC1044D Maxillary quad helix with finger springs $325 D8220* DPC1045D Maxillary and mandibular retainer with pontics $175 D8210* DPC1046D Maxillary Schwarz $250 D82tO* DPCAO TD Maxillary splint $225 D82tO* DPC1048D Mobile intraoral Arch-Mia (similar to a Bihelix for nonex- $100 traction treatment) D8220* DPC1049D Modified quad helix appliance $275 D8220* DPC1050D Modified quad helix appliance (with appliance) $275 D8220* DPC1051D Nance appliance $10o D8220* DPC1052D Nasal stent $250 D82LO* DPC1053D Occlusal orthotic device $175 * = Services payable to an FQHC for a client encounter
CPf only copynght 2007 American lvledical Assæiat¡on All r¡ghts reseryed L94L Section 19
Procedure Remarks Maximum Code Code Remarks Code Descliption Fee D82LO* DPC1054D Orthopedic appllance $250 D8210* DPC1O55D Other mand¡bular utilities $100 D8210* DPC1O56D Other maxillary utilities $100 D8220* DPC1057D Palatal bar $225 D8210'r. DPC1058D Post-surg¡cal retainer $125 D8220* DPC1059D Quad helix appliance held with transpalatal arch horizontal $275 projections D8220* DPC1060D Quad helix maintainer $275 D8220* DPC1061D Rapid palatal expander (RPE), such as quad Helix, Haas, or $350 Menne D8210* DPC1062D Removable bite plate $100 D82LO* DPC1063D Removable mandibular retainer $100 D8210* DPC1O64D Removable maxillary retainer $100 D8210* DPC1065D Removable prosthesis $175 D8210* DPC1066D Sagittal appliance 2 way $250 D8210* DPC1067D Sagittal appliance 3 way $350 D8220* DPC1068D Stapled palatal expansion appliance $375 08210* DPC1069D Surgical arch wires $250 D82LO" DPC1070D Surgical splints (surgical stenti/wafer) $250 D8210* DPC1071D Surgical stabilizing a ppliance $250 D8220* DPC]-OT2D Thumbsucking appliance, requires submission of models $175 D8210* DPC1073D Tongue thrust appliance, requires submission of models $1oo D82LO* DPC1074D Tooth positioner (full maxillary and mandibular) $325 D8210* DPC1O75D Tooth positioner with arch $10o D8220" DPC1076D Transpalatal arch $100 D8220* DPQ|OTTD Two bands with transpalatal arch and horizontal projections $175 forward D8220* DPC1078D W-appliance $275 * = Services payable to an FQHC for a client encountel.
L9.2O How to Score the Handicapping Labiolingual Deviation (HLD) lndex The orthodontic provider must complete and sign the diagnosis (Angle class)' Gleft Palate Submita cleft palate case inthe mixed dentition only if itcan be justified in a narrative whythere should be treatment before the client is in the full dentition. Note: lntermittent treatment requests may exceed the allowable 26 reimbursable treatment v¡s¡ts. Severe Traumatic Deviations Refers to facial accidents only. Points cannot be awarded for congen¡tal deformity. Severe traumatic deviations do not include traumatic occlusions for crossbites. Overjet in Millimeters Score the case exactly as measured, then subtract 2 mm (considered the norm), and enter the difference as the score.
L942 CPT only copyrght 2007 American Medrcal Assciat¡on All rights reseryed Append¡x H Append¡x I R49 – tadlock spreadsheet Ectopic score
Ectopic score Antoine HLD
Tadlock HLD # ANTOINE SCORES - BY TOOTH
Upper Lower 3 2 1 1 2 3 3 2 1 1 2 3 1 1 1 1 1 1 1 1 1 26 24 0 0 2 1 1 1 1 1 1 1 1 32 24 4 0 3 1 1 1 1 1 1 1 1 26 24 2 0 4 1 1 1 1 1 1 1 1 1 1 1 1 38 36 11 6 5 1 1 1 1 1 1 1 1 27 24 9 0 6 1 1 1 1 1 1 1 1 27 24 1 0 7 1 1 1 1 1 1 1 1 32 24 19 0 8 1 1 1 1 1 1 1 1 35 24 5 0 9 1 1 1 1 1 1 1 1 27 24 10 0 10 0 0 6 0 11 1 1 1 1 1 1 1 1 27 24 5 0 12 1 1 1 1 1 1 1 1 1 1 1 1 36 36 7 3 13 1 1 1 1 1 1 1 1 1 1 1 1 36 36 0 0 14 1 1 1 1 1 1 1 1 1 1 33 30 2 0 15 1 1 1 1 1 1 1 1 1 1 1 1 55 36 28 0 16 1 1 1 1 1 1 1 1 1 1 36 30 13 0 17 1 1 1 1 1 1 1 1 1 1 1 1 39 36 3 0 18 1 1 1 1 1 1 1 1 28 24 10 0 19 1 1 1 1 1 1 1 1 1 1 1 1 40 36 16 0 20 1 1 1 1 1 1 1 1 1 29 27 7 0 21 1 1 1 1 1 1 1 1 30 24 9 0 22 1 1 1 1 1 1 1 1 28 24 3 0 23 1 1 1 1 1 1 1 1 28 24 9 0 24 1 1 1 1 1 1 1 1 29 24 1 0 25 1 1 1 1 1 1 1 1 27 24 1 0 26 1 1 1 1 1 1 1 31 21 12 0 27 1 1 1 1 1 1 1 1 29 24 3 0 28 1 1 1 1 1 1 1 1 28 24 0 0 29 1 1 1 1 1 1 1 1 29 24 5 0 30 1 1 1 1 1 1 1 1 28 24 3 0 31 1 1 1 1 1 1 1 1 26 24 5 0 32 1 1 1 1 1 1 1 1 1 1 1 1 44 36 15 0 33 1 1 1 1 1 1 1 1 1 1 1 1 48 36 12 0 34 1 1 1 1 1 1 1 1 1 30 27 7 0 35 1 1 1 1 1 1 1 1 31 24 6 0 36 1 1 1 1 1 1 1 1 29 24 10 0 37 1 1 1 1 1 1 1 29 21 15 6 38 1 1 1 1 1 1 26 18 4 0 39 1 1 1 1 1 1 1 1 27 24 7 0 40 1 1 1 1 1 1 1 1 1 1 33 30 4 0 41 1 1 1 1 1 1 1 1 30 24 7 0 42 1 1 1 1 1 1 1 1 28 24 12 6 43 1 1 1 1 1 1 1 1 27 24 1 3 44 11 0 45 1 1 1 1 1 1 1 1 1 31 27 0 0 46 1 1 1 1 1 1 1 1 1 1 1 1 36 36 4 3 47 1 1 1 1 1 1 1 1 35 24 8 0 48 1 1 1 1 1 1 1 1 32 24 7 0 49 1 1 1 1 1 1 1 1 1 1 34 30 7 0 50 1 1 1 1 1 1 1 1 27 24 12 0 51 4 0 52 1 1 1 1 1 1 29 18 3 0 53 1 0 54 1 1 1 1 1 1 1 1 1 1 1 1 36 36 1 0 55 1 1 1 1 1 1 1 1 1 1 1 1 39 36 7 3 56 1 1 1 1 1 1 1 1 30 24 6 0 57 1 1 1 1 1 1 1 1 35 24 4 0 58 1 1 1 1 1 1 1 1 1 1 1 1 36 36 11 0 59 1 1 1 1 1 1 1 1 1 1 30 30 0 0 60 1 1 1 1 1 1 1 1 30 24 6 0 61 1 1 1 1 1 1 1 1 1 1 1 1 36 36 11 6 62 1 1 1 1 1 1 1 1 1 1 1 1 36 36 14 0 63 1 1 1 1 1 1 26 18 10 0
R49 - tadlock spreadsheet.Revised.xlsx Page 1 Append¡ J SOAH DOCKET NO. XXX-XX-XXXX HHSC-OIG CASE NO.: P2011131652384891
ANTOINE DENTAL CENTER, § BEFORE THE STATE OFFICE Petitioner § § v. §OF § § TEXAS HEALTH & HUMAN § ADMINISTRATIVE HEARINGS SERVICES COMMISSION, OFFICE § OF INSPECTOR GENERAL, § Respondent § § HHSC-OIG’s PROFFER OF REBUTTAL TESTIMONY FROM DR. LINDA ALTENHOFF
TO THE HONORABLE ADMINISTRATIVE LAW JUDGES:
COMES NOW the Texas Health and Human Services Commission, Office of
Inspector General (“HHSC-OIG”), and requests the ability to recall Dr. Linda Altenhoff
to offer rebuttal testimony. HHSC-OIG offers the following proffer of expected
testimony from Dr. Altenhoff:
PROFFER
Q: Dr. Altenhoff, you are the same Linda Altenhoff who testified on day one of this hearing, correct?
A: lam.
Q: Have you been in attendance during all of the testimony given by the various witnesses?
A: Ihave been.
Q: Specifically, did you hear the testimony of Dr. Orr and Dr. Kanaan?
A: Idid.
000695 Q: Did you hear their testimony regarding the meaning of ectopic eruption as used by Texas Medicaid?
Q: Dr. Altenhoff, did Medicaid intend, at any time, for the term “ectopic eruption” to have a different meaning when used in the evaluation of Medicaid patients than is generally understood in the practice of dentistry?
A: No.
Q: Were dentists expected to employ the training and education they received as dentists in applying the terms used in the Provider Manual?
A: Yes.
For these reasons, HHSC-OIG prays to be allowed to recall Dr. Linda Altenhoff
for limited rebuttal testimony in keeping with the above proffer.
Respectfully submitted,
GREG ABBOTT Attorney General of Texas
DANIEL T. lODGE First Assistant Attorney General
JoHN B. SCOTT Deputy First Assistant Attorney General
RAYMc(pJC. WINTER State Bar No. 21791950 Chief, Civil Medicaid Fraud Division (512) 936-1709 MARGARET MOORE State Bar No. 14360050
000696 Deputy Chief, Civil Medicaid Fraud Division (512) 936-1319 direct dial
Assistant Attorneys General P.O. Box 12548 Austin, Texas 78711-2548 (512) 499-0712 fax
Va aoc’e
Dan Hargrove State Bar No. 00790822 WATERS & KRAUS, LLP 3219 McKinney Avenue Dallas, Texas 75204 (214) 357-6244 Telephone (214) 357-7252 Facsimile
m
James Moriarty State Bar No. 14459000 MORIARTY LEYENDECKER, PC 4203 Montrose Blvd, Suite 150 Houston, TX 77006 (713) 528-0700 Telephone
000697
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Cite This Page — Counsel Stack
Texas Health and Human Services Commission and Office of Inspector General v. Antoine Dental Center, Counsel Stack Legal Research, https://law.counselstack.com/opinion/texas-health-and-human-services-commission-and-office-of-inspector-general-texcrimapp-2015.